Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0272), and a prophylaxis (D1110), provided on January 5, 2021.
You asked the Plan to pay for a periodic oral evaluation, bitewing x-rays, and a prophylaxis. You say that the services should be covered. The Plan denied your request. The Plan says that you received care from a provider who has opted out of Medicare, and therefore, the services are not covered 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 periodic oral evaluation, bitewing x-rays, and a prophylaxis when the services are medically necessary and reasonable. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, bitewing x-rays, and a prophylaxis have been met. Specifically, there was not a private contract signed between you and your provider and there is no clear language in the Plan's EOC stating supplemental benefits cannot be obtained by providers who have opted out of Medicare. This means the Plan can pay for supplemental benefits received by providers who have opted out of Medicare. Therefore, we decided that the Plan has to pay for a periodic oral evaluation (D0120), bitewing x-rays (D0272), and a prophylaxis (D1110), provided on January 5, 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the cervical spine (72125).
You asked the Plan to pre-approve a CT scan of the cervical spine. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan of the cervical spine. Our reviewer says that the services are medically necessary. Our physician reviewer found the request for CT of the cervical spine by the neurosurgeon to assist in surgical planning is indicated and reasonable. The CT is a better test for bone and calcium detail than magnetic resonance imaging (MRI). The surgeon has explained the rationale for needing the CT and the approach and necessity for the requested CT in order to better plan the enrollee's surgery is medically reasonable and necessary. 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 CT scan of the cervical spine have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the cervical spine (72125).
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 pre-approve pontics (D6240) for tooth #'s 8, 9, and 10, and retainer
crowns (D6750) for tooth #'s 6, 7, and 11.

You asked the Plan to pre-approve the pontics and retainer crowns. You say that you need these services to be
approved for coverage. The Plan denied your request. The Plan says these services are not medically necessary.

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 pontics
and retainer crowns 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 pontics and retainer crowns. Our reviewer says that given the Plan limitations on fixed bridgework, the requested treatment would not meet the criteria presented for an anterior bridge. Our physician reviewer found tooth #'s 8 and 10 previously had a three unit bridge replacing tooth #9. Our reviewer also found that in this instance there would be replacement of three anterior upper teeth using double abutments on the upper right and a single abutment on the upper left. 

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 pontics and retainer crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve pontics (D6240) for tooth #'s 8, 9, and 10, and retainer crowns (D6750) for tooth #'s 6, 7, and 11.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's needs
are being met at the current skilled nursing facility.

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 physician reviewer found
that the enrollee was admitted to the acute care hospital for surgical repair of a hip fracture after a fall. Her
medical conditions are stable. There are no complex nursing needs. She does not require treatment by multiple
therapies in an intensive rehabilitation therapy program. She does require physical and occupational therapy,
but there is no documented need for an intensive rehabilitation program.

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided November 3, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee required transport by ambulance due to weakness, poor trunk control and requiring O2. Please see attached documents, review and reprocess the referenced claim for reprocessing. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the BLS non-emergency ambulance (A0428) and ground mileage (A0425) provided November 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee has not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a partial resection of the right middle turbinate (30999) provided on November 12, 2020.

You asked the Plan to pay for a partial resection of the right middle turbinate. You say that this was used to report a partial resection of the right middle turbinate. The Plan denied your request. The Plan says that the records do not support the billed code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 a partial resection of the right middle turbinate. Our reviewers says that this code is supported in the records. Our physician reviewer found a remark on the original claim specifies this was used to report a partial resection of the right middle turbinate. The official CPT codebook designates CPT 30999 is to be used when describing a fracture of the nasal middle or superior turbinate. The operative report documents that the physician "trimmed the lateral aspect of the middle turbinate." 

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 partial resection of the right middle turbinate have been met. Therefore, we decided that the Plan has to pay for a partial resection of the right middle turbinate (30999) provided on November 12, 2020.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 8,
2020, to January 6, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee
required no nursing services which would be considered skilled services by Medicare.

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 pay for the skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from December 8, 2020, to January 6, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular genetic variant screening provided on
December 10, 2020.

You asked the Plan to pay for the cardiovascular genetic variant screening. You say that you would like
reconsideration because this testing is medically necessary due to the member's condition. The Plan denied
your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels except the
basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease.

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 cardiovascular genetic variant screening. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. If the member notes cardiac symptoms these would be evaluated directly with appropriate cardiac specific testing based on the symptomatology. 

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 cardiovascular genetic variant screening have not been met. Therefore, we decided that the Plan does not have to pay for cardiovascular genetic variant screening provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office services (CPT code 99205) provided on July 19, 2019, by an out-of-network provider.

You asked the Plan to waive the copayment for the office services. You say that you were under the impression the provider was in-network and has continued to see the provider and now this is coming back as out-of-network. The Plan denied your request. The Plan says there was no evidence that you contacted the plan to inquire about the provider's participation status prior to the date of service in question.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

Review of the file show that you received the office services on July 19, 2019, by an out-of-network provider. You were asked to pay 50% coinsurance for the out-of-network office services. Your 2019 EOC states that enrollees must pay 50% coinsurance of the Medicare-allowed amount after the $950 yearly out-of-network deductible for out-of-network Physician/Practitioner services, including doctor's office visits. 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 copayment for the office services (CPT code 99205) provided on July 19, 2019, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (D7140)
received December 31, 2020.

You asked the Plan to pay for the extraction. You say that the requested service was necessary. The Plan denied
your request. The Plan says the claim was not submitted with a valid diagnosis code; therefore, the claim
cannot be processed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the tooth extraction have not been met. Specifically, the record shows that the claim form was
billed without a valid diagnosis code. The Plan requires a diagnosis code for processing of this type of service.
Based on this information, we decided that Medicare rules for coverage of the extraction have not been met.
Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root
(D7140) received December 31, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee
from July 11, 2020 to July 14, 2020.

You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically
necessary. The Plan denied your request. The Plan says that the member was hemodynamically stable and did
not meet criteria for inpatient level of care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. The patient presented to the emergency department due to a fall. Workup was negative for significant injury. Laceration was repaired without complication. The patient and/or the family was deemed unable to care for the patient, and so she was admitted. The patient was hemodynamically stable and did not have an acute condition which warranted inpatient services. She could have been treated at a lower level of care. There was no expectation that the patient would have required hospital services that would have likely crossed 2 midnights based on the provided documentation. Our physician reviewer found that the enrollee's condition did not meet Medicare criteria for acute inpatient hospital 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 the acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided to the enrollee from July 11, 2020 to July 14, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.

You asked the Plan to pre-approve Orthovisc. You say that the medication is necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.

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 Orthovisc. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found the request is for a viscosupplement
which is not a Step one medication. There is no evidence of the superiority of one agent over another.
Therefore, the request is deemed not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Orthovisc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial observation care (99220) provided May 18, 2020.

You asked the Plan to pay for the initial observation care. You say that these services were medically necessary. The Plan denied your request. The Plan says the medical records do not support the care as it was billed.

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 99220 is Initial observation care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 

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 initial observation care. Our reviewer says that the documentation does not support the code billed as 99220. Our physician reviewer found the review indicates that the enrollee was a then 65-year-old male who arrived at the emergency department on May 18, 2020, after being found intoxicated on the street. He was evaluated with a physical exam, laboratory studies, and diagnostic x-rays including CT scans of the head, abdomen, and pelvis. He was admitted to observation with undifferentiated intoxication/substance abuse and pancreatitis. The review indicates that the medical records in this case did not support the CPT code billed of 99220. 

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 initial observation care have not been met. Therefore, we decided that the Plan does not have to pay for the initial observation care (99220) provided May 18, 2020.