Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2additional occupational therapy visits from July 21, 2020through August 14, 2020.You asked the Plan to pre-approve the 2 additional occupational therapy visits. The Plan denied your request. The Plan says the documentation provided on appeal does not state the enrollee's prior level of function or show loss of function requiring ongoing occupational therapy services nor that occupational therapy visits are required to maintain current function andor prevent further deterioration.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 the 2 additional occupational 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 the requested additional 2 occupational visits fromJuly 21, 2020, through August 14, 2020 would nothave been generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has hadpriortherapy for this condition and it didnot appear that the enrollee's functional level required the unique skills of a professional therapist to safely and effectively provide treatment, that the services could have been safely and effectively performed only by a therapist or under the supervision of a therapist. The enrollee was trained in an independent exercise program andthe July 16, 2020 occupational therapy note reveals the enrollee can groom self-independent, dress upper body, dress lower body without assist, with use of device can bathe self independently, independent for toilet hygiene and transfers. Furthermore, there is conflicting documentation on the homebound status during these dates as the July 16, 2020 document notes that there wasno difficult or taxing effort to leave the home and the July 19, 2020 document states "considerable effort" to leave the home but this is contradictory to the notation that the enrollee has full endurance and stable oxygen and heart rate levels and functional level. Thespecialized skill, knowledge and judgment of a qualified therapist was not required to establish, design and/or deliver a program to maintain the enrollee's 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 the 2 additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional occupational therapy visits from July 21, 2020, through August 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia, 60 mg/ml syringe, every 6 months. 
 
You asked the Plan to pre-approve Prolia. You say that the injection is necessary. The Plan denied your 
request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 
drugs are covered under a Medicare Part D prescription drug plan. The Plan says the requested drug is not 
covered for your condition under Medicare Part B. 
 
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 Prolia, 60 mg/ml syringe, 
every 6 months.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre sensor and reader. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific 
criteria are met. 
 
We looked at the file and Medicare rules. The file shows that the enrollee is not insulin-treated. 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 a Freestyle Libre sensor and reader.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OnabotulinumtoxinA (Botulinum Toxin A) injection. 
 
You asked the Plan to pre-approve OnabotulinumtoxinA. You say that the requested injection into external 
obliques indicates that this is imperative for repairing her hernias. The Plan denied your request. The Plan says 
medical studies have not proven that the drug is helpful for treatment of incisional hernia without obstruction or 
gangrene. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 OnabotulinumtoxinA. Our reviewer 
says that the requested drug is not medically necessary. Our physician reviewer found OnabotulinumtoxinA is 
not FDA-approved for the enrollee's diagnosis. The reviewer found the use of Botulinum Toxin A as an agent 
for chemodenervation/chemical component separation pre-operatively for complex abdominal wall 
reconstruction after parastomal and ventral hernia repair is not supported by the major drug compendia. The 
reviewer also found that the clinical research in the medical literature is insufficient to demonstrate that 
Botulinum Toxin A is safe and effective in this 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 OnabotulinumtoxinA have not been met. Therefore, we decided that the Plan 
does not have to pre-approve OnabotulinumtoxinA (Botulinum Toxin A) injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture. 
 
You asked the Plan to pre-approve the complete mandibular denture. You say that the dentist offered you a 
temporary lower denture to use until your gums healed, and you could have a permanent one. You also say that 
if you had known you would be using your denture benefit on a temporary one, you would have waited until 
the permanent denture was ready. The Plan denied your request. The Plan says this benefit has been exhausted. 
 
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, dentures are limited to one upper and 
one lower denture every five years. The record shows that you received a mandibular immediate denture on 
January 9, 2020, and your mandibular denture benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pre-approve a complete mandibular denture.
 
Your complaint about being misled by the provider 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on May 20, 2020. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says when a billing group bills a member with multiple claims on the same date of service, a 
modifier is needed to specify that services are not duplicate. Per the Medicare Claims Processing Manual 
30.6.6, a modifier should only be used on claims for evaluation and management (E/M) services, and only 
when these services are provided by the same physician (or same qualified nonphysician practitioner) to the 
same patient on the same day as another procedure or other service. This claim did not include the necessary 
modifier.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code and when necessary report the required modifier.  
In this case, the claim was not submitted with the required modifier. Medicare rules for coverage of this service 
have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to 
the enrollee on May 20, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided to the enrollee on December 5, 
2019 out of network. 
 
You asked the Plan to pay for this service.  You say that this claim should be paid. The Plan denied your 
request. The Plan says the ordering physician was out of network and the enrollee did not have prior 
authorization for out of network care.  
 
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 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 medical services provided to 
the enrollee on December 5, 2019 out of network.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional intraoral periapical x-ray and panoramic x-ray 
provided on June 4, 2020. 
 
You asked the Plan to pay for the additional intraoral periapical x-ray and panoramic x-ray. You say that you 
contacted the Plan and were told these services would be covered in full. You also say that you were unaware 
you received this service last year, and it was only covered every five years. The Plan denied your request. The 
Plan says the benefits for these services have been satisfied and the frequency limitations have been exceeded. 
 
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, intraoral x-rays and are limited to one 
procedure per calendar year. The record shows that you received a first intraoral periapical x-ray on June 4, 
2020, and your intraoral x-rays benefit has been exhausted. The contract also says that full mouth or panoramic 
x-rays are limited to one procedure every five years. The record shows that you received a panoramic x-ray on 
December 10, 2019, and your full mouth and panoramic x-rays benefits have been exhausted. Therefore, we 
decided that the Plan does not have to pay for the additional intraoral periapical x-ray and panoramic x-ray 
provided on June 4, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Lite Glucometer kit. 
 
You asked the Plan to pre-approve the Freestyle Lite Glucometer. You say that the glucometer is medically 
necessary. The Plan denied your request. The Plan says the requested glucometer is not covered because it is 
not made by a preferred manufacturer. 
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers.  
 
 
We looked at the file and Medicare rules. The plan preferred brand for diabetes testing supplies is Accu-Chek. 
The requested Freestyle Lite monitor is not made by the plan preferred manufacturer. No medical records were 
provided to show why the plan preferred Accu-Chek meter would not be appropriate for the enrollee. Based on 
this information, we decided that Medicare rules for coverage of the Freestyle Lite Glucometer have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Lite Glucometer kit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from 
October 13, 2020, to discharge. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 inpatient mental health care. Our 
physician reviewer found based upon review the records provided it was not expected this patient would 
improve in a reasonable period of time beyond the dates in question as the patient was not showing any 
dangerousness to self or others, no auditory or visual hallucinations and no abnormal behaviors. This patient 
was 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 
they 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 patient did not require inpatient 
mental health treatment beyond the dates in question as noted above as the patient was not a danger to 
themselves 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. Our physician reviewer was unable to find an individualized treatment plan however 
the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based 
upon review the records provided, this patient does not meet the criteria for treatment in an acute inpatient 
mental health treatment beyond the date in question of October 13, 2020 forward and could have been treated 
in a lesser restrictive setting as the patient was not showing any suicidal or homicidal ideation, auditory or 
visual hallucinations and was not showing any behaviors being cooperative and compliant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve continuation of inpatient mental health care from October 13, 2020, to 
discharge.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the selective catheter placement services coded 36215 
provided on February 17, 2020. 
 
You asked the Plan to pay for the selective catheter placement 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 supported by the 
documentation. 
 
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 36215 is selective catheter placement, arterial system; 
each first order thoracic or brachiocephalic branch, within a vascular family. 
 
We find that CPT code 36215 is not supported in the medical record. Specifically, the operative report did not 
include documentation of a selective catheter placement into the arterial system, for each first order thoracic or 
brachiocephalic branch, within a vascular family. Based on this information, we decided that Medicare rules 
for coverage of the selective catheter placement services have not been met. Therefore, we decided that the 
Plan does not have to pay for the selective catheter placement services coded 36215 provided on February 17, 
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided June 2, 2020. 
 
You asked the Plan to pay for the critical care services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the services were billed incorrectly. 
 
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 find that CPT code 99291 is not supported in the medical record. Specifically, the record shows another 
physician in the same group billed for the same services on the same day. Based on this information, we 
decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided 
that the Plan does not have to pay for critical care services (99291) provided June 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on February 14, 
2020. 
 
You asked the Plan to waive the copayment for lab services. You say that you were told that there should be no 
charge for this service. The Plan denied your request. The Plan says the coinsurance you are being charged is 
correct. 
 
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 20% 
coinsurance for in-network lab services in an outpatient hospital setting.  
 
The allowed amount of the claim is $221.53, resulting in a coinsurance obligation of $55.39 for lab services. 
Lab services fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 
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 lab services provided on February 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the automatic blood pressure monitor (CPT Code 
A4670). 
 
You asked the Plan to pre-approve the automatic blood pressure monitor. You say that the device is necessary. 
The Plan denied your request. The Plan says this is not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only 
for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require 
ABPM to confirm a diagnosis of hypertension.  
 
The records do not show that this monitor is requested in the setting of home dialysis services, or that this 
request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home 
may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. 
Therefore, we decided that the Plan does not have to pre-approve the automatic blood pressure monitor (CPT 
Code A4670).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not 
been met. 
 
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 spinal surgery. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no documentation of spinal instability. Conservative measures for the past 12 months 
have not been completed. More and recent physical therapy (PT) is needed. Criteria for spinal fusion surgery 
has not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sedation services (G0500) provided February 24, 2020. 
 
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the records do not support the services 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 G0500 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing a gastrointestinal endoscopic service that 
sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the 
patient's level of consciousness and physiological status. 
 
We find that CPT code G0500 is not supported in the medical record. Specifically, the record does not show 
that a trained observer was present to assist in monitoring the patient. Based on this information, we decided 
that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the 
Plan does not have to pay for sedation services (G0500) provided February 24, 2020.