Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on January 21, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95937 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. We find that CPT code 95937 is not supported in the medical record. Specifically, the records show that Train of Four testing was performed and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on January 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed.
You asked the Plan to pre-approve the total electric hospital bed. You say that the PCP also agrees that the
enrollee requires a hospital bed and you would like to appeal the denial. The Plan denied your request. The
Plan says this item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric
hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on July 30, 2019 by an out of network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for lab work provided on July 30, 2019 by an out of
network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on December 13, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot
be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on December 13, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation.
You asked the Plan to provide coverage for additional routine transportation. You say that additional transportation is necessary. The Plan denied your request. The Plan says once this benefit is exhausted it cannot be extended.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year. Once this benefit is exhausted it is not extended by Medicare or the Plan. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the collagen based wound filler and gauze provided on
December 2, 2019.
You asked the Plan to pay for the collagen based wound filler and gauze. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not supported.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain a valid physician order for the supplies provided in this case. No physician order
was provided in the records. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pay for the collagen based
wound filler and gauze provided on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation
submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests
are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the drug testing services provided on August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bath/shower chair (E0240).
You asked the Plan to pre-approve the bath/shower chair. You say that you cannot stand in the shower for a
long time. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health
Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve bath/shower chair (E0240).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond June 6,
2020.
You asked the Plan to pre-approve the continued inpatient psychiatric services. You say that the enrollee has
needed to remain in inpatient status since admission and requires ongoing inpatient care. The Plan denied your
request. The Plan says beyond June 6, 2020, the enrollee could have been managed in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continued inpatient psychiatric
services. Our reviewer says that the documentation does not support that continued inpatient care is medically
reasonable and necessary. Our physician reviewer found this 74-year-old male was admitted to the acute
inpatient psychiatric hospitalization on May 29, 2020 with Major Neurocognitive Disorder with Behavioral
Disturbance. Based upon review the records provided it was not expected this enrollee would improve in a
reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or
others, no auditory or visual hallucinations and no abnormal behaviors. This patient was calm and compliant
with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the
acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have
any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan's denial of
continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental
health treatment beyond the dates in question as noted above as he was not a danger to himself or others and
did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment
was taking place beyond the date in question. It did not appear that the services for the dates in question were
reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the continued inpatient psychiatric services have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond June 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (CPT 99190) provided on November 1, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99100). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (CPT 99190) provided on November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1390) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the DME. You say that a smaller tank on your back will allow you to walk more freely and will decrease the risk of an injury that a big tank may cause. The Plan denied your request. The Plan says they have approved you to get an oxygen concentrator with their contracted vendor and you will receive an approved authorization with the provider's contract information in the mail.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The DME is available within the network and your condition is not an emergency. Instead, the Plan states that you are approved to get an oxygen concentrator from their contracted vendor. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1390) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you required contact guard assistance to minimal assistance with transfers. You
required stand-by assistance with bed mobility. You required minimal assistance with walking with a gait belt
for 100 feet in divided sessions. The documentation does not support evidence of complex medical issues that
require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need
for acute rehab nursing care. While you may benefit from further physical therapy and occupational therapy,
you do not require an intensive therapy program. Your care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Test Strips.
You asked the Plan to pre-approve One Touch Test Strips. You say that you would like to keep using the meter
you already have. The Plan denied your request. The Plan says that the non-preferred durable medical
equipment (One Touch Test Strips) is not a covered benefit under the contractual agreement.
The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.
The items at issue are One Touch test strips. One Touch is not a preferred provider with the Plan for diabetic
supplies. Therefore, we decided that the Plan does not have to pre-approve One Touch Test Strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve securement loops (K0108), for the enrollee.
You asked the Plan to pre-approve the item. You say that the item is medically necessary. The Plan denied your
request. The Plan says the item is not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The purpose of these straps is to allow for travel outside of the home with the power wheelchair. The straps are
not mainly used for a medical purpose. The item at issue in this appeal does not serve a purpose that is
primarily medical in nature. This item is available to the general public and would be helpful even to those who
are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve securement loops
(K0108), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says IRF admission is not medically necessary. Services could be met at a lower level of care such as a skilled nursing facility, outpatient setting or home health care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that her functional level requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Risperidone tablets.
You asked the Plan to pre-approve Risperidone tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Risperidone tablets are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Risperidone tablets.
Benefits for Risperidone tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 19, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on August 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #12.
You asked the Plan to pre-approve the crown. You say that a full-coverage crown is recommended for tooth
#12 as definitive restoration. The Plan denied your request. The Plan says the obturation is not filled
sufficiently close to the radiographic apex, and the concern is that the unobturated canal space which may
contain microorganisms and/or debris may potentially lead to infection, abscess, bone loss, pain and/or
swelling. The Plan also says that in its current state is not recommended, and does not meet the coverage
criteria under the enrollee's supplemental benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the crown
when the services are medically necessary and reasonable.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the crown. Our reviewer says that the
service is not medically necessary. Our physician reviewer found the criteria for coverage have not been met
for a crown restoration (D2750). Our reviewer also found that either the root canal must be redone or a
narrative as to why the endodontic filling is short of the apices must be submitted.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have
to pre-approve a crown (D2750) for tooth #12.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve left atrial appendage closure therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the
requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has ongoing intermittent atrial fibrillation in spite of 2 ablation procedures now being
considered for placement of a Watchman device. The documentation does not support that the enrollee is under
the care of a multidisciplinary team including two independent non-interventional cardiologists. In addition,
one electrophysiologist does not recommend proceeding with the procedure due to increased risk.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the therapy have not been met. Therefore, we decided that the Plan does not
have to pre-approve left atrial appendage closure therapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you needs grab bars to keep from falling while
taking a shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because
they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pre-approve a grab bar.