Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Balloon Sinuplasty.
You asked the Plan to pre-approve nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (31295). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says since the enrollee has not been treated sufficiently with nonsurgical treatments to know if the proposed surgery is necessary the Balloon Sinuplasty cannot be approved.
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 nasal/sinus endoscopy, surgical, with
dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (31295). Our reviewer
says that the requested service is not considered medically reasonable and necessary in this case. Our physician
reviewer found the documentation does not support that there has been failure of medical management in this
case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary
sinus ostium, transnasal or via canine fossa (31295) have not been met. Therefore, we decided that the Plan
does not have to pre-approve Balloon Sinuplasty.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for airline tickets purchased on August 25, 2020.
You asked the Plan to pay for airline tickets. You say that you want the Plan to reimburse you for airline tickets because you had to return home due to Coronavirus. The Plan denied your request. The Plan says airline tickets are not a covered benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of transportation have not been met. Specifically, the transportation benefit is limited to transportation by ambulance. Airline tickets are not a covered benefit of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for airline tickets purchased on August 25, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says you have met all your goals.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional services. Our physician reviewer found that the additional therapy is not generally accepted as effective therapy for your condition beyond what was approved by the health plan. You have had extensive prior therapy. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist.
You have been instructed in a home exercise program. The requested services are not part of a maintenance program. The services of a qualified therapist are not required to establish, design or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you are requesting an evaluation for special supplemental benefits. The Plan denied your request. The Plan says The Plan says you do not qualify for the special supplemental benefit for chronic diseases.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 6, 2021.
You asked the Plan to pay for the comprehensive oral exam. You say that you were told an oral exam would be covered. The Plan denied your request. The Plan says you have exceeded frequency limits for this service.
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 comprehensive oral exam once every three plan years. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on April 11, 2019. Based on this information, we decided that the Plan's rules for
coverage of the comprehensive oral exam have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) provided April 6, 2021.
Your complaint about potentially being provided misinformation by a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement CPAP machine (CPT code E0601).
You asked the Plan to pre-approve the DME. You say that you need to breathe at night. You state it is a
medical necessity and it has been recalled. You state you were told not to use it. The Plan denied your request.
The Plan says the documentation submitted by your provider did not report that your CPAP equipment is lost,
irreparably damaged (unable to be fixed), or that your medical condition has changed such that the current
equipment is no longer meeting your needs.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Medicare requires that for replacement of equipment less than five (5) years old, there must be documentation showing that the equipment is lost or irreparably damaged (unable to be fixed); or your medical condition changes such that the current equipment is no longer meeting your needs. As there is no documentation that your CPAP equipment is lost, irreparably damaged, or that your medical condition has changed such that the current equipment is no longer meeting your needs, Medicare criteria are not met and the request is denied. Therefore, we decided that the Plan does not have to pre-approve replacement CPAP machine (CPT code E0601).
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 intensive rehabilitation therapy is necessary for you to rebuild your strength and regain maximum functioning ability. You have mobility issues and cannot stand or walk on your own. The Plan denied your request. The Plan says the criteria for an IRF are not met, and the services you require can safely be provided in a lower level of 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 in the Medicare rules section. 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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided March 15, 2021.
You asked the Plan to pay for the limited oral exam. You say that this service should not have been considered an evaluation. The Plan denied your request. The Plan says you have exceeded frequency limits for this service.
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 limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on January 12, 2021. Based on this information, we decided that the Plan's rules for
coverage of the limited oral exam have not been met. Therefore, we decided that the Plan does not have to pay
for the limited oral evaluation - problem focused (D0140) provided March 15, 2021.
Your complaint about the oral surgeon potentially being provided misinformation is not a valid appeal for
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does
not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve center mount elevating leg rests (CPT code K0108), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not covered. The Plan states K0108 Angle Adj Center Mount is miscoded. The correct code of this item is E1012.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Center mount elevating Leg rests are not medically necessary. Elevating leg rests are medically necessary for management of edema, for use with reclining back or if the enrollee has cast or condition that prevent 90-degree knee flexion. The enrollee has none of these conditions. The elevating leg rests cannot be covered. Therefore, we decided that the Plan does not have to pre-approve center mount elevating leg rests (CPT code K0108), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 provided on March 22, 2021.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not payable.
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 80307 is drug test(s), presumptive, any number of drug
classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay
[eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry
either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD,
MALDI, TOF) includes sample validation when performed, per date of service.
We find that CPT code 80307 is not supported in the medical record. Specifically, only one code of 80305,
80306, or 80307 can be billed per enrollee per date of service. The documentation shows that code 80305 was
billed on March 22, 2021. This means that the frequency guidelines for code 80307 have been exceeded. Based
on this information, we decided that Medicare rules for coverage of the drug testing have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 provided on March
22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s)
(eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including
needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging
guidance (ie, fluoroscopy or CT) (CPT code 62321).
You asked the Plan to pre-approve the injection. You say that you are having pain in your thoracic area of your
spine and having to spend most of the date on the heating pad, lying in bed. The Plan denied your request. The
Plan says this injection 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 injection. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found thoracic epidural steroid injection (ESI) remains experimental for thoracic pain management.
You do have thoracic stenosis but ESI remains experimental in the thoracic spine for pain management. More
research is needed to show safety and efficacy.
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) (CPT code 62321).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency care provided on March 3, 2021.
You asked the Plan to waive the copay for the services provided. You say that you should not have to pay two copays because it was for the same problem. The Plan denied your request. The Plan says the claim processed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copay for emergency care. You have been asked to pay a $90 copay for the services provided. The services fall within the emergency care benefit category. The Plan contract says that you pay a copay each time you receive certain medical services. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copay for the emergency care provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the inpatient care provided from October 29, 2020, to November 4, 2020.
You asked the Plan to pay an additional amount for the inpatient care. You say that the treating physician
appropriately assigned the secondary diagnosis to the enrollee. The Plan denied your request. The Plan says the
provided documentation does not support the major complication or comorbidity (MCC) that was recorded.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with secondary diagnosis code, R53.2, defined as
functional quadriplegia. 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 pay for the inpatient care.
Our reviewer says that in this case, you billed the inpatient services provided with secondary diagnosis code,
R53.2, defined as functional quadriplegia. Our physician reviewer found the medical records that were
provided do not support the billing of functional quadriplegia, ICD-10-CM code R53.2.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Specifically, the file does not support the billing of the
secondary diagnosis code of functional quadriplegia. Therefore, we decided that the Plan does not have to pay
an additional amount for the inpatient care provided from October 29, 2020, to November 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional physical therapy visits. You say that you incorrectly attached older documentation to the request and the denial was due to a clinical error. The Plan denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that ongoing physical therapy will not result in practical improvement in his level of function within a reasonable and predictable period. Our reviewer says that the request for 12 physical therapy visits does not meet medical necessity criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the fixed partial denture sectioning (D9120).
You asked the Plan to pre-approve the fixed partial denture sectioning (D9120). You say that you want the tooth extracted but it is under the dental bridge. You say that the bridge needs to be sliced and you want the service covered. The Plan denied your request. The Plan says the service is not a covered benefit.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the fixed partial denture sectioning (D9120).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on February 1, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the drug is
not covered under the medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs.
The medical records show that you received Plavix during your outpatient care. Drugs that are normally selfadministered,
that you get during outpatient care, are not among the types which are covered by Medicare Part
B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on
February 1, 2021.
Benefits for the services provided 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dermatology office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a dermatology office visit. You say that you have always been treated by the requested provider. The Plan denied your request. The Plan says dermatology services are available in-network.
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 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 dermatology office visit to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing.
You asked the Plan to pre-approve BRCA 1 and 2 testing. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that BRCA1/BRCA2 genetic testing is not reasonable and necessary for individuals with no personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. We looked at the file and Medicare rules. The records do not show that the enrollee has a personal history of breast, ovarian, fallopian tube, primary peritoneal, pancreatic, or prostate cancer. This means that BRCA1/BRCA2 genetic testing is not considered reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of BRCA 1 and 2 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA 1 and 2 testing.