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

We decided that the Plan does not have to waive the copayment for a biopsy provided on October 22, 2020.
You asked the Plan to waive the copayment for a biopsy. You say that you should only owe a $200 copayment and disagree with the additional $50 charge. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received a biopsy at an outpatient hospital facility on October 22, 2020. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a biopsy. A biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a biopsy provided on October 22, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve hammertoe surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necesasry. The Plan denied your request. The Plan says that there is no documentation of conservative measures attempted.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found it is well-established in the documentation that the enrollee has a painful second toe hammertoe both clinically and radiographically. The enrollee has advised that they have difficulty ambulating, due to this painful contracted toe. A hammertoe is considered a biomechanical malformation of a toe, that can certainly lead to pain during gait. The surgery is considered standard 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 the surgery have been met. Therefore, we decided that the Plan has to pre-approve hammertoe surgery for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and removal of an impacted
tooth (D7230).
You asked the Plan to pre-approve the dental services. You say that you have an impacted molar. You say that
it is affecting the way that you eat. You say that it is giving you headaches that make you immobile. You say
that you are unable to pay for the procedure. You also say that it is causing your dentures and original teeth to
shift in your mouth which is uncomfortable. The Plan denied your request. The Plan says consultation is not
listed as a covered service. The Plan says that removal of an impacted tooth is not listed as a covered service
either. The Plan also says that any services not listed are not covered.
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 a
consultation (D9310) and removal of an impacted tooth (D7230).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional ten (10) occupational therapy visits.
You asked the Plan to pre-approve an additional ten (10) occupational therapy visits. The Plan denied your request. The Plan says additional occupational therapy 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 an additional ten (10) 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 additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy for this condition with minimal significant objective improvement and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in Kegel exercises with CGA and visual cues and has the support of caregivers and staff to continue an independent exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist 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 an additional ten (10) occupational therapy visits. have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional ten (10) occupational therapy visits.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a repeat transthoracic echocardiogram for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show a change in medical condition.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found there is a typographical error in the provider appeal letter, as the prior echocardiogram in question was done on 3/17/20, not on 3/27/21 as stated in the letter. This prior echocardiogram (the report is included in the records) was done more than one year ago, not four weeks ago as stated by the plan. The enrollee has persistent and increasing shortness of breath. She had diastolic dysfunction noted on an echo in 3/17/2020 and is being treated for this along with her hypertension. The enrollee qualifies for a repeat assessment of left ventricular systolic and diastolic function and her response to medical therapy, most especially in light of changing and progressive dyspnea symptoms over the past year. 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 services have been met. Therefore, we decided that the Plan has to pre-approve a repeat transthoracic echocardiogram for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept system.
You asked the Plan to pre-approve Intracept Procedure (22899), Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), and Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753). . You say that this procedure is the most viable treatment to achieve relief of chronic low back pain. The Plan denied your request. The Plan says a review of the current medical literature indicates 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 Intracept Procedure (22899), Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), and Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753).
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for the treatment of low back pain. More research is needed to show safety and efficacy of the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept Procedure (22899), Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (C9752), and Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance
(e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure) (C9753) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20600) provided on June 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 20600 is "Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance". We asked our coding 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 CPT code 20600 is not supported by the records provided. Our coding reviewer found that the operative report does not document arthrocentesis, aspiration and/or injection was performed. Therefore, this service cannot be verified as performed. Arthrocentesis is the clinical procedure of using a syringe to collect synovial fluid from a joint capsule, or injection. This was not documented in the operative report. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (20600) provided on June 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September
18, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. 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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, the requested laboratory testing is not considered medically necessary as it is not
considered basic cardiovascular risk stratification. Furthermore, there is no indication that the enrollee has an
appropriate medical condition for this testing.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services provided to the enrollee on September 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that you were lied to and now you do not have any upper teeth. The Plan denied your request. The Plan says complete upper denture us not listed as a covered dental item.
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 a complete upper denture (D5110).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
You asked the Plan to pre-approve the therapeutic continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for the therapeutic continuous glucose monitor have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
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 inpatient surgery is approved but bone marrow aspirate 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of bone marrow aspirate remains experimental for spinal fusion. More research is needed to show safety and efficacy. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says MRI is the more appropriate choice here.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the scan. Our reviewer says that the requested CT scan is not medically reasonable or necessary. Our physician reviewer found an MRI of the pelvis is appropriate and indicated in this situation as the first study to properly restage this enrollee's cancer. Locally advanced disease is more likely to occur in this case and is best determined with MRI. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the abdomen and pelvis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the care can be safely received in another setting, such as a skilled nursing facility, or home with home health services.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cataract removal surgery provided on
October 13, 2020.
You asked the Plan to waive the copayment for the cataract removal surgery. You say that you would like the
Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received cataract
removal surgery on the date of service at issue in this appeal. The Plan says that the correct copayment has
applied per the enrollee's contract with the Plan.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $350 copayment for Outpatient surgery.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received cataract
removal surgery on October 13, 2020. The enrollee has been asked to pay a $350 copayment for the cataract
removal surgery. The cataract removal surgery falls within the Outpatient surgery benefit category. This means
that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing
is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the
Plan does not have to waive the copayment for the cataract removal surgery provided on October 13, 2020.
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 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 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, 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 required to establish a maintenance program
or to prevent deterioration of your condition. Your care needs at this point 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 SNF care.