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

We decided that the Plan does not have to pay for scaling and root planing for 4 or more teeth per quadrant (D4341), scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 3), the complete series x-ray (D0210), and the nitrous oxide (D9250 x 2) provided from March 24, 2021, to March 25, 2021.
You asked the Plan to pay for the dental services. You say that you were not able to locate an in network provider. You say that a plan representative advised you could see an out of network provider and still have the services covered as in network. You also say that your claims were denied. The Plan denied your request. The Plan says scaling and root planing, 1 procedure code every 3 years, per quadrant. The Plan says that panoramic x-ray or complete series x-ray once every 5 years. The Plan says that these frequency limits have been exceeded. the Plan also says that nitrous oxide is only covered when performed in conjunction with other covered services.
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 the services are listed as covered,
the frequency limits have been exceeded. The record shows that the Plan paid for scaling and root planing for
the upper right and lower right quadrants that you received on May 13, 2019. The record shows that the Plan
paid for scaling and root planing for the upper left and lower left quadrants that you received on May 20, 2019.
The record shows that the Plan paid for a panoramic x-ray that you received on April 30, 2019. Additionally,
nitrous oxide is not covered unless performed in conjunction with other services that are covered. Therefore,
we decided that the Plan does not have to pay for scaling and root planing for 4 or more teeth per quadrant
(D4341), scaling and root planing for 1 to 3 teeth per quadrant (D4342 x 3), the complete series x-ray (D0210),
and the nitrous oxide (D9250 x 2) provided from March 24, 2021, to March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on
October 12, 2020, billed with code 99202-25.
You asked the Plan to pay for the EM services as billed. You say that this was billed correctly and should be
paid. The Plan denied your request. The Plan says this was billed incorrectly as a new patient visit.
The Plan must follow Medicare rules. Medicare rules say that for EM services, the phrase "new patient" means
a patient that has not been treated by the provider/provider group in the past 3 years.
In this case, code 99202 is for a new patient visit. However, the file shows that this patient was seen and had an
EM visit on September 25, 2019 with this physician. As such, a new patient EM code is not appropriate.
Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) services
provided on October 12, 2020, billed with code 99202-25.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar (CPT code 22633), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee's notes do not show that the enrollee's back-pain origin has been located. The enrollee's doctor's notes do not show this; therefore, this procedure (lumbar decompression/fusion) 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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for lumbar spinal fusion not met. There are no flexion and extension films showing instability of the segment. Fusion is not warranted and criteria for fusion not 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar (CPT code 22633), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an initial annual wellness visit (G0438) provided March 22, 2021.
You asked the Plan to pay for an initial annual wellness visit. You say that this is payable as billed. The Plan denied your request. The Plan says this was not billed correctly.
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 G0438 is annual wellness visit; includes a personalized prevention plan of service (pps), initial visit. We find that CPT code G0438 is not supported in the medical record. Specifically, the record shows that the enrollee previously had an annual wellness visit with this provider in 2019. It is not appropriate to bill an initial visit in this case. Based on this information, we decided that Medicare rules for coverage of an initial annual wellness visit have not been met. Therefore, we decided that the Plan does not have to pay for an initial annual wellness visit (G0438) provided March 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional routine transportation
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that the additional PT is medically
necessary. The Plan denied your request. The Plan says additional PT is 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 ten (10) additional PT 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 extensive prior therapy 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 by or under the supervision of a
therapist. The enrollee participates in an independent exercise program and can continue to do so. 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 patient'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 ten (10) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus booster (CPT code 90714) provided on January 15, 2021.
You asked the Plan to pay for the tetanus booster. You say that you had your annual physical and your primary care physician determined you needed a tetanus booster. The Plan denied your request. The Plan says while the plan upholds denial of the claim submitted under your Part C Medical Benefits the plan notes a claim for the services was submitted and paid under your Part D Benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the tetanus booster. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the tetanus booster. Therefore, we decided that the Plan does not have to pay for the tetanus booster (CPT code 90714) provided on January 15, 2021.
Benefits for the tetanus booster may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the discontinued exploratory laparotomy provided in the outpatient setting on June 11, 2020, billed with code 49000.
You asked the Plan to pay for the outpatient laparotomy. You say that this was provided in the outpatient setting because the procedure was discontinued before the patient was formally admitted. The Plan denied your request. The Plan says this is an inpatient-only code and must be billed on an inpatient claim.
The Plan must follow Medicare rules. Medicare rules say that the OPPS designates certain codes as inpatient-only, and these cannot be billed on outpatient claims. Though this was discontinued, the code for this service is inpatient-only. There is no approved outpatient payment amount for this service. It can only be paid on an inpatient claim. Therefore, we decided that the Plan
does not have to pay for the discontinued exploratory laparotomy provided in the outpatient setting on June 11, 2020, billed with code 49000.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services (CPT code 99214) to be performed by an out-of-network ophthalmologist.
You asked the Plan to pre-approve the office services. You say that the service is necessary. The Plan denied your request. The Plan says the services can be performed by an in-network provider.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services (CPT code 99214) to be performed by an out-of-network ophthalmologist.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five (5) additional OT visits.
You asked the Plan to pre-approve five (5) additional OT visits. You say that additional OT is medically
necessary. The Plan denied your request. The Plan says additional OT is 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 five (5) additional OT 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 approved 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 by or under the supervision of a therapist. The enrollee has
been provided sufficient therapy sessions that would allow him and caregiver staff to transition to
independence. 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 five (5) additional OT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve five (5) additional OT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically
necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is medically stable and has been provided medical clearance to undergo these elective procedures. The planned procedures listed under CPT codes 36216, 37246, and 36140 are not listed on the CMS Inpatient Only
List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to
support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional PT visits.
You asked the Plan to pre-approve the additional PT. You say that you would like reconsideration because the member has not reached maximum improvement. The Plan denied your request. The Plan says there is no evidence the member requires the continued unique skills of a therapist to restore or maintain function.
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 additional PT. 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 the requested services are not part of a maintenance program and the
specialized skill, knowledge and judgement of a qualified therapist are not required to establish, design and/or
deliver a program to maintain the member's current condition or to prevent 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 additional PT have not been met. Therefore, we decided that the Plan does
not have to pre-approve 10 additional PT visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this service is medically necessary for
the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a
LTACH admission.
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 that in this case the enrollee, who is quadriplegic, was admitted with sepsis from a
urinary tract infection. The enrollee currently is febrile with purulent drainage from a sacral pressure ulcer.
The enrollee continues to receive acute care services that have not been denied. The medical record does not
indicate that the enrollee requires services that he is not currently receiving but that would be available at the
LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be
recommended.
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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to a LTACH is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care and does not require transfer to a LTACH.
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 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 long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
December 12, 2020, through December 14, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the member did not meet lnterQual guidelines 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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found that the enrollee was sent to the hospital by his hemodialysis center to rule out
COVID-19 due to fever, fatigue and intermittent chills for one week. The enrollee was found to be COVID-19
positive and was treated with antibiotics for suspected pneumonia on chest X-ray. The enrollee was admitted
for dialysis. His vitals were stable. Based on the provided documentation, the enrollee was hemodynamically
stable, not hypoxic, and only required dialysis which would have been only a few hours. It was not expected
that the enrollee would have required inpatient hospital care that would have likely crossed 2 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 not been met. Therefore, we decided that the
Plan does not have to pay for the acute inpatient hospital care provided from December 12, 2020, through
December 14, 2020.