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

We decided that the Plan does not have to pay for surgical services (CPT 27245) provided to the enrollee on June 22, 2019. 
 
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 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 27245 is "treatment of intertrochanteric, peri trochanteric, or sub trochanteric femoral fracture;with intramedullary implant, with or without interlocking screws and/or cerclage." 
 
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 services at issue in this case were not supported by the medical records. Our physician reviewer found the medical records provided do not include documentation that Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with intramedullary implant, with or without interlocking screws and/or cerclage was performed on June 22, 2019. The medical records indicate that a procedure was performed on June 23, 2019. However, the date of service CPT code 27245 was billed to the health plan was for June 22, 2019. Since there is no documentation to validate that this services occurred on June 22, 2019, CPT 27245 is not eligible for reimbursement consideration. 
 
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 surgical services (CPT 27245) provided to the enrollee on June 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 services are not medically necessary. Our physician reviewer found the records show that you were admitted to the hospital on March 24, 2020 with a leg and arm fracture. You were treated non-operatively. You need assistance with dressing, bed mobility, and transfers. You have no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may benefit from further therapy but do not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient admission for the Zephyr valve system procedure.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says that medical treatment can be optimized in an outpatient setting.
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 admission. Our reviewer says that the requested admission is considered medically reasonable and necessary in this case. Our physician reviewer found an inpatient stay of at least three nights after EBV placement is considered medically necessary. The enrollee has severe COPD with emphysema, and appears to be a good candidate for lung volume reduction using EBV. The inpatient stay is necessary because of the high risk of pneumothorax in the first three days following the procedure. In patients with severely impaired lung function, pneumothorax can life-threatening, and can require immediate treatment in order to preserve life. The FDA's approval of EBV includes the requirement of a three night hospital stay. 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 admission have been met. Therefore, we decided that the Plan has to pre-approve an inpatient admission for the Zephyr valve system procedure.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial observation care (99220) provided on August 2, 2019.
You asked the Plan to pay for the initial observation care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says observation care may only be reported by the physician who ordered hospital outpatient observation services and was responsible for the patient during his/her observation care.
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 99220 is not supported in the record. Specifically, the record indicates that another initial observation care code was processed and paid for this enrollee on this date of service. 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 initial observation care (99220) provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extraction (D7140) and the filling (D2331) provided from December 11, 2019 to December 18, 2019.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says the $150 allowance has been exhausted. The Plan also says that the benefit was used for the filling that you received on April 2, 2019.
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 and extractions and fillings are covered services, the $150 allowance was exhausted prior to receiving the services. The record shows that the allowance was exhausted after receiving a filling on April 2, 2019. Therefore, we decided that the Plan does not have to pay for the surgical extraction (D7140) and the filling (D2331) provided from December 11, 2019 to December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 13, 2019 to the enrollee by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
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 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 the medical services provided on June 13, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from October 10, 2019 through October 18, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from October 10, 2019 through October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you have seen this provider for the last seven years. You say that this visit was previously arranged. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 an office visit provided on October 7, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for breast prosthesis mastectomy bras purchased on November 9, 2019 from a non-participating Medicare provider.
You asked the Plan to pay for the DME. You say that you were not aware that the provider was not Medicare approved. The Plan denied your request. The Plan says the provider does not participate with Medicare.
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 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 breast prosthesis mastectomy bras purchased on November 9, 2019 from a non-participating Medicare provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ABPM (A4670) provided to the enrollee on October 31, 2019.
You asked the Plan to pay for the ABPM. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ABPM have not been met. The ABPM is only covered for suspected white coat hypertension, and must be performed for at least 24 hours to meet coverage criteria. Suspected white coat hypertension is defined as 1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 2. At least two documented blood pressure measurements taken outside the office which are <140/90mm Hg; and3. No evidence of end-organ damage. ABPM is not covered for any other uses. Therefore, we decided that the Plan does not have to pay for the ABPM (A4670) provided to the enrollee on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift.
You asked the Plan to pre-approve a seat lift. You say that you have a hard time getting up from a sitting position. The Plan denied your request. The Plan says that there is no indication in the submitted clinical information that you have severe arthritis of the hip or knee or that you have a severe neuromuscular disease.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 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 seat lift. Our reviewer says that a seat lift is not medically reasonable and necessary in this case. The documentation does not reveal objective imaging studies revealing severe arthritis of the hip or knee. There is no evidence of a neuromuscular disease. The records do not show that a seat lift is included in the treating practitioner's course of treatment. The seat lift will not likely effect improvement in your condition or arrest or retard deterioration in your condition. The records do not show that you are completely incapable of standing from a chair in the home. Our physician reviewer found that your condition does not meet Medicare criteria for a seat lift. 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 seat lift have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter ablation provided on October 10, 2019.
You asked the Plan to pay for the catheter ablation. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 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 catheter ablation provided on October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 24, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on October 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for elbow orthosis (CPT Code L3761) provided to the enrollee on September 23, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says you do not have an appropriate face-to-face encounter documented in the records to substantiate the need for this item.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. Under Medicare guidelines, your request is not medically necessary because the records show you do not have an appropriate face-to-face encounter documented in the records to substantiate the need for this item. We reviewed your records and they show that the enrollee was seen by the provider for back pain. There is no mention in the records of any elbow pain or instability. There is no mention of the need for elbow bracing. The problem list in the medical record does not list elbow pain as one of the enrollee's problems. There was no specific physical examination of the elbow. There is an order for an elbow brace signed on September 16, 2019. There is no commensurate note in the medical record on or around that date as to why the brace was being ordered. Therefore, we decided that the Plan does not have to pay for elbow orthosis (CPT Code L3761) provided to the enrollee on September 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion surgery.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary due to extreme pain and discomfort. The Plan denied your request. The Plan says it cannot be determined if all other sources of pain have been excluded.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found more conservative measures are needed. There are no red flags for surgery. Physical therapy must be tried. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion surgery.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for chiropractic service provided on July 19, 2019.
You asked the Plan to pay for chiropractic service. You say that this is part of your Plan and should be covered.
The Plan denied your request. The Plan says that the denial of payment for this service is correct, because more
appropriate diagnosis codes are needed for the services rendered.
The Plan must follow Medicare rules. Medicare rules say that chiropractic service is covered when billed with
the associated diagnosis codes M99.01, M99.02, or M99.03.
We looked at the file and Medicare rules. This chiropractic service was billed with appropriate diagnosis codes
for Medicare coverage. Based on this information, we decided that Medicare rules for coverage of chiropractic
service have been met. Therefore, we decided that the Plan has to pay for chiropractic service provided on July 19, 2019.
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.