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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. At this point, the enrollee's care needs are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further pay for the eyeglasses items (V2020, V2781, V2750, V2784) provided April 19, 2021.
You asked the Plan to further pay for the eyeglasses items. You say that you believe you are not responsible for the amount you are being charged. The Plan denied your request. The Plan says the claim has processed correctly in this case.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services with a $200 allowance for supplemental eyewear every year. We looked at the file and the Plan's rules. In this case, the Plan has fully provided the $200 allowance for supplemental eyewear. However, the total claim was $299 for the eyewear leaving you with a total liability of $99. Based on this information, we decided that the Plan's has met the contractual obligation for supplemental eyewear. Therefore, we decided that the Plan does not have to further pay for the eyeglasses items (V2020, V2781, V2750, V2784) provided April 19, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on August 23, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was not in Hospice on the date of service in dispute. You say that the hospice end date was 6 days before the date of service in dispute. The Plan denied your request. The Plan says fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on August 17, 2020. The services in question were provided before the end of that month.
Therefore, we decided that the Plan does not have to pay for ambulance services provided on August 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.

You asked the Plan to pre-approve a portable ventilator. You say that this is to be used for the treatment of chronic obstructive pulmonary disease, unspecified and acute and chronic respiratory failure with hypercapnia. The Plan denied your request. The Plan says that the requested device would be used in a Bilevel positive airway pressure (BiPAP) mode that could be provided with a BiPAP device with average volume-assured pressure support (AVAPS) added to assure adequate tidal volumes.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 a portable ventilator. Our reviewer says that a portable ventilator is not medically reasonable and necessary for the enrollee. The member's significant co-morbidities include morbid obesity, hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), obstructive sleep apnea syndrome (OSAS) non-compliant with CPAP, chronic diastolic heart failure, coronary artery disease (CAD), chronic renal insufficiency (CRI), gastroesophageal reflux disease (GERD), peripheral vascular disease (PVD), and prior pulmonary embolism (PE) now presenting with chronic respiratory failure (CRF). The member was recently admitted to an inpatient service for acute on chronic respiratory failure (ACRF). He improved with treatments including IV diuretics and steroids, inhaled corticosteroids and bronchodilators, supplemental oxygen and BiPAP therapy. The use of a portable ventilator to deliver ventilatory support via settings that could be equally provided by a BiPAP with AVAPS settings is inconsistent with coverage rules. The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a portable ventilator.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99212) provided on March 1, 2021.

You asked the Plan to pay for a chiropractic office visit. You say that you needed this service. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99212) provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The superion spacer remains experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Superion interspinous spacer for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the RightMed Test and Gene Report provided on March 4, 2021.
You asked the Plan to pay for the RightMed Test and Gene Report. You say that you would like reconsideration because the billed services were medically necessary. The Plan denied your request.
The Plan says procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the beneficiary and using the results in the management of the beneficiary's specific medical problem.
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 pay for the RightMed Test and Gene Report. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the requested laboratory studies. The records show that the physician who is treating the beneficiary will use the results in the management of the beneficiary's specific medical problem. 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 RightMed Test and Gene Report have not been met. Therefore, we decided that the Plan does not have to pay for the RightMed Test and Gene Report provided on March 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that you were hospitalized for metabolic encephalpathy. You state you require skilled therapy for weakness and falls since admission. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on March 3, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M are not covered for the CxBladder test. We looked at the file and Medicare rules. In this case, code 0012M was billed for the CxBladder test. This is not a covered code for this test. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing (0012M) provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for an eye refraction (routine eye exam) provided on May 17, 2021.
You asked the Plan to pay for eye refraction. You say that you could not see clearly and needed to see a
specialist. The Plan denied your request. The Plan says that the denial of payment for this service is correct,
because this service is not covered by Medicare.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when performed by a doctor in the Plan's vision network.
We looked at the file and the Plan's rules. This service is covered by the Plan's supplemental vision benefits
when performed by a Plan vision network provider. Based on this information, we decided that the Plan's rules
for coverage of eye refraction have been met. Therefore, we decided that the Plan has to pay for an eye
refraction (routine eye exam) provided on May 17, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid you received from an out-of-network provider on January 12, 2021.
You asked the Plan to pay for the hearing aid. The Plan denied your request. The Plan says the out-of-network services are not covered.
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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the hearing aid you received from an out-of-network provider on January 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 5, 2021.

You asked the Plan to pay for a comprehensive oral evaluation. You say that you feel the dentist you saw in 2020 was fraudulent. The Plan denied your request. The Plan says this is only covered once every three years.

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 a comprehensive oral evaluation once every three years. 

We looked at the file and Medicare rules. The record shows that you received a comprehensive oral evaluation in 2020. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from February 27, 2020, to March 5, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with an inappropriate diagnosis code.
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 diagnosis codes A41.89 and R65.20. 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 services. Our reviewer says that the use of diagnosis codes A41.89 and R65.20 is not supported by the records provided. Our physician reviewer found that in this case, the SOFA score was 0 as there was no evidence of dysregulated immune-mediated organ injury. Therefore, there was a lack of objective clinical evidence to support the diagnosis of sepsis. 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. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from February 27, 2020, to March 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral exam, problem focused (D0140) and core buildup (D2950) provided June 1, 2020.
You asked the Plan to pay for the dental services. You say that it is your understanding that in-network, the Plan would pay 30% of the cost of the crown. D2740 also states in network there is 30% coverage. The crown cost $1,298.00, therefore a refund of $389.40 would be applicable. The Plan denied your request. The Plan says D0140 and D2950 are not covered under the Plan benefits. Periapical x-rays were approved in error but will remain paid.
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 pay for limited oral exam, problem focused (D0140) and core buildup (D2950) provided June 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician or other qualified health care professional services for outpatient cardiac rehabilitation services coded 93798 provided on April 12, 2021.

You asked the Plan to pay for the physician or other qualified health care professional services for outpatient cardiac rehabilitation services. 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 claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 93798 is 2. The MAI value for this code is 2. You billed 8 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the physician or other qualified health care professional services for outpatient cardiac rehabilitation services have not been met. Therefore, we decided that the Plan does not have to pay for the physician or other qualified health care professional services for outpatient cardiac rehabilitation services coded 93798 provided on April 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approve Repetitive Transcranial Magnetic Stimulation (rTMS).
You asked the Plan to pre-approve rTMS. You say that the requested rTMS is medically necessary. The Plan
denied your request. The Plan says that the enrollee does not meet criteria for the requested rTMS.
The Plan must follow Medicare rules. Medicare rules say that items and services that are medically necessary
are 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 rTMS. Our reviewer says that the
enrollee does meets criteria for the requested rTMS. Our physician reviewer found the enrollee is diagnosed
with Bipolar Disorder and Major Depressive Disorder, Recurrent, Mild to Moderate. The LCD specifically
requires the confirmed diagnosis to be Severe Major Depressive Disorder Single or Recurrent as well as
resistance of treatment with pharmacologic agents as evidenced by lack of clinical significant response to trials
of pharmacologic agents in the current depressive episode from at least two different agent classes along with
concurrent documented psychotherapy. This enrollee does possess the diagnosis as noted above. She had been
tried on pharmacologic agents from different categories for which she has had very little improvement although
it is unclear what episode of depression this enrollee had taken these medications as it is not outlined as a
current episode. There is no mention of the enrollee desiring electroconvulsive treatment even though it is in
the record. Utilizing the information from this enrollee indicates this enrollee does have an indication for the
requested Repetitive Transcranial Magnetic Stimulation (rTMS), based on the records provided, this enrollee
does meet the criteria for treatment with Repetitive Transcranial Magnetic (rTMS).
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of rTMS have been met. Therefore, we decided that the Plan has to pre-approve
Repetitive Transcranial Magnetic Stimulation (rTMS).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.