Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like reconsideration because the IRF admission is medically necessary.The Plan denied your request. The Plan says the member's needs may be safely met at a lower level of care.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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical status does not currently require intensive physician ornursing supervision 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran alveoloplasty procedure (D7321) performed on August 20, 2020.You asked the Plan to pay foran alveoloplasty. You say that you feel this service should be covered for any of those areas where your teeth were pulled.The Plan denied your request. The Plan says rules for payment have not been met.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 pay foran alveoloplasty procedure (D7321) performed on August 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea total left shoulder replacement.You asked the Plan to pre-approvethese services. 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. 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. Ourphysician reviewer found the enrollee has been treated for bilateral shoulder rotator cuff arthropathy. Imaging demonstrated bilateral shoulder rotator cuff arthropathy and severe cuff wasting. Furthermore, exam findings only notes that shoulder range of motion is "fair". Documentation of specific ranges of motion is not evident. There is no detailed indication of deltoid motor function on exam. Large-scale, randomized, controlled references do not support reverse total shoulder arthroplasty in the settingof severely impaired deltoid function. Therefore, the requested left total shoulder replacement would not be standard of care. The total left shoulder replacement is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea total left shoulder replacement.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approvea partial lower denture (D5214).You asked the Plan to pre-approvethe dental item. You say that you have tooth decay. You also say that you are eating on your gums. The Plan denied your request. The Plan says that dentures are covered once per arch, per 60 months. The Plan says that the frequency limit for this service has been reached.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide any documentation to substantiate that they had previously paid any money for a partial lower denture. Without this documentation we cannot verify whether or not the benefit allowance has been exhausted.Therefore, we decided that the Plan has to pre-approvea partial lower denture (D5214).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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the carpectomy (25210), finger biopsy (26110), knuckle joint fusion (26516) and carpal tunnel surgery (64721) provided on September 8, 2020.
You asked the Plan to pay for the surgery. You say that you would like reconsideration because the surgery is delicate and an assistant at surgery is medically necessary. The Plan denied your request. The Plan says an assistant at surgery may not be paid for these services.
The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for CPT codes 26516 and 25210. The Medicare Fee Schedule Database contains a surgical indicator of 0 for these procedures. 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 surgery. Our reviewer says that the services of an assistant surgeon were not medically necessary for CPT codes 26516 and 25210. Our physician reviewer found the provided documentation does not demonstrate significant complexities that would require an assistant surgeon. The procedure codes 26516 and 25210 found on the CMS fee schedule are noted to be "0" indicating that an assistant surgeon is not typically warranted. Operative note provided, again does not provide significant medical complexity to indicate otherwise. Medicare rules say that if the database contains an assistant at surgery indicator of 1 for the surgical procedure in question, Medicare has determined that an assistant is not medically necessary. Assistant surgeons will not be paid for these procedures. CPT codes 64721 and 26110 have an assistant at surgery indicator of 1. This means that an assistant at surgery may not be paid for these 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pay for the carpectomy (25210), finger biopsy (26110), knuckle joint fusion (26516) and carpal tunnel surgery (64721) provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLantus Solostar for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee needs this for diabetes.The Plan denied your request. The Plan says that this is not covered under 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-approveLantus Solostar for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgery to be providedat the out-of-network facility.You asked the Plan to pre-approve the surgery to be provided at the out-of-network facility.You say that you do all of your surgeries at this hospital. You say that your team is highly experienced,and you believe the skill set of your surgical team contributes to good patient outcomes. The Plan denied your request. The Plan says there are participating providers and facilities that can provide the requested services within the enrollee's provider system.The enrollee must receive care from a network provider. In most cases, care the enrollee receivesfrom an out-of-network providerwill not be covered.The Plan covers emergency care or urgently needed services from anout-of-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 providersavailable who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve surgery to be providedat the out-of-network facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean upper partial denture.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services 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-approvean upper partial denture.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea complete maxillary denture and complete mandibular denture.You asked the Plan to pre-approvethe complete maxillary denture and complete mandibular denture. You say that your previous dentures were not made correctly. You also say that you have had extractions and your dentures no longer fit.The Plan denied your request. The Plan says these services are only covered one time in a 60 month time period. The Plan also says that you have already had these services done in that time period.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, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a mandibular partial denture on October 1, 2018, and a complete maxillary denture on February 11, 2019, and your dentures benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea complete maxillary denture and complete mandibular denture.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe harness for upgrade to expandable controller identified with code E2313, the expandable controller identified with code E2377, and the electronic connection between wheelchair controller and two or more power seating system motors identified with code E2311.You asked the Plan to pre-approvethe harness for upgrade to expandable controller, the expandable controller, and the electronic connection between wheelchair controller and two or more power seating system motors. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested items are not covered.The Plan must follow Medicare rules. Medicare rules say that wheelchair accessories are only covered for certain indications.We looked at the file and Medicare rules. Although there are three approved power options on the requested wheelchair (tilt, recline, and elevating leg rests), there is no medical need to control these power options through the joystick. The enrollee has 3 to 3+ strength in the upper limbs. The enrollee is able to performed tasks independently. Therefore, the enrollee's upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these power options. Based on this information, we decided that Medicare rules for coverage of the harness for upgrade to expandable controller, theexpandable controller, and the electronic connection between wheelchair controller and two or more power seating system motors have not been met.Therefore, we decided that the Plan does not have to pre-approvethe harness for upgrade to expandable controller identified with code E2313, the expandable controller identified with code E2377, and the electronic connection between wheelchair controller and two or more power seating system motors identified with code E2311.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pay forthe interpretation of the coronary CT scan provided on August 17, 2020.You asked the Planto pay forthe CT interpretation. You say that this was billed correctly and should be paid.The Plandenied your request. The Plansaysthatthe enrollee was in an inpatient admission starting on August 15, 2020. As such, the place of service (POS) code should be for inpatient, instead of outpatient.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan's denial rationale states that this claim should be billed with the inpatient POS code since the enrollee was a registered inpatient at the time of service. The claim was billed with an outpatient POS code. Review of the inpatient claim provided by the plan shows that 5 days of inpatient care were provided between August 15, 2020, and August 23, 2020. In counting inpatient days, the discharge date is not counted. This would indicate that the enrollee was admitted to inpatient status as of August 18, 2020. Based on this information, it is not clear that an inpatient POS code would be appropriate for the services provided on August 17, 2020. We find that the denial rationale is not supported by the available information.Therefore, we decided that the Planhas to pay forthe interpretation of the coronary CT scan provided on August 17, 2020.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental services (D7230, D9222, D9223).You asked the Plan to pre-approvethe dental services. You say that the services are medically necessary.The Plan denied your request. The Plan says out-of-network dental services are not a covered benefit.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. Only services obtained from plan-participating providers are eligible for coverage.Therefore, we decided that the Plan does not have to pre-approvedental services (D7230, D9222, D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forchemotherapy injections (J9034, J9312, J9312) provided on November 10, 2020.You asked the Plan to waive the coinsurance forchemotherapy injections. You say that you should be charged less because you pay a premium.The Plan denied your request. The Plan says this processed correctly.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 Medicare-covered Part B drugs. You have been asked to pay a $1,436.78 coinsurance for chemotherapy injections, which are Medicare-covered Part B drugs benefit category ($7,183.91 allowed amount x 20% = $1,436.78). 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 coinsurance forchemotherapy injections (J9034, J9312, J9312) provided on November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea seat lift mechanism and recliner chair.You asked the Plan to pre-approvethese services. You say that you have medical conditions that do not allow you to lift yourself up.The Plan denied your request. The Plan says the seat liftmechanism is not medically necessary.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. The rules say that Medicare does not cover equipment that does not serve a purpose that is primarily medical in nature.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 seat lift mechanism is not medically necessary. Our physician reviewer found the records do not show that you have imaging evidence of severe arthritis of the hip and/or a neuromuscular disease. The requested seat lift mechanism is not clearly documented in the progress notes as a course of treatment. The seat lift is not likely to improve your condition or slow deterioration of your condition. The records do not show that you are completely incapable of standing from a chair in the home. The seat lift mechanism is not reasonable or medically necessary.The requested recliner chair does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.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-approvea seat lift mechanism and recliner chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A4465.
You asked the Plan to pre-approve the compression stockings. 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. The rules say that compression stockings described by code A4465 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A4465.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora retroperitoneal ultrasound (CPT 76775) provided to the enrollee on April 10, 2020.You asked the Planto pay forthe ultrasound. You say that this should be paid for.The Plandenied your request. The Plansaysthere is no additional documentation supporting an additional study which was billed and remains denied.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 76775 is "Ultrasound, retroperitoneal (eg, renal, aorta, nodes), real time with image documentation."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 ultrasound. Our reviewer says that the additional unit of ultrasound is not supported in the medical records. Our physician reviewerfound there is no evidence in the case file to pay for an additional unit.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 ultrasoundhave not been met.Therefore, we decided that the Plandoes not haveto pay fora retroperitoneal ultrasound (CPT 76775) provided to the enrollee on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 20 and August 27, 2020, by an out of network provider.
You asked the Plan to pay for nursing facility care. You say that the enrollee was in-house at the nursing facility. The Plan denied your request. The Plan says rules for payment have not been met.
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 had network providers available who could have provided 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 August 20 and August 27, 2020, by an out of network provider.