Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approvea dermatology referral.You asked the Plan to pre-approvethe referral. You say that you would like reconsideration because you need to see a dermatologist for your condition which did not improve with treatment.The Plan denied your request. The Plan says that there is noinformation to show that prescription therapy has been tried and failed.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the referral. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the pimple on the occupital skin and positive skin lesion need to be evaluated by a dermatologist to rule out skin pathology other than acne.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 referral have been met.Therefore, we decided that the Plan has to pre-approvea dermatology referral.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 etter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroutpatient surgery services provided to the enrollee on June 26, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysan outpatient removal of a vulvar lesion is not reasonable due to a lack of clinical information to justify an actual removal was performed.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 services at issue in this case were not supported by the medical records submitted. Our physician reviewer found there is no evidence that any lesion of any kind was removed on the date of service in question. Additionally, there is no documentation to confirm in the code was actually billed. Therefore, the billing of CPT56516 is not supported.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 Plandoes not haveto pay foroutpatient surgery services provided to the enrollee on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (76376, 93320, 93325) provided on September 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed services are not 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 76376 is "3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation".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 use of CPT code 76376 is not supported by the records provided. Our physician reviewer found that while the documentation indicates that a 3D rendering may have been performed, the 3D rending has not been provided for review. Therefore, there is no evidence to support the service as billed.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 76376 have not been met. Medicare rules also say that add-on codes can only be reported in addition to a primary procedure. When the CPT Manual identifies specific primary codes, the add-on is not payable unless one of the primary codes is paid on the same claim. The primary procedure code in this case is not payable, and therefore the add-on codes 93320 and 93325 are also not payable.Therefore, we decided that the Plan does not have to pay forthe services (76376, 93320, 93325) provided on September 12, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the eye exam (92004) provided on October 18, 2019.You asked the Plan to waive the copaymentfor the eye exam. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the cost sharing has been applied correctlyas you are responsible for a $35 copayment for the eye exam provided.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 paya $35 copayment for physician services provided to diagnose and treat diseases and conditions of the eye. You have been asked to paya $35 copaymentfor the eye exam provided. 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 copaymentfor the eye exam (92004) provided on October 18, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you had fallen out of your power chair and had hit your head. You say that you were forced by the circumstances to call 911 because you could not get back into your chair without help. You stated that you live alone and are self-sufficient so far. You say that you do notunderstand why a rescue department in your area of coverage was not called to help you.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 8, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of the health problem.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is considered experimental. More research is needed to show safety and efficacy.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 device have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean interspinous and/or interlaminar device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthe medical group has several head and neck specialists who can evaluate and treat your medical condition.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 Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveToric (astigmatism-correcting lens).You asked the Planto pre-approvethe lens. You say that this is medically necessary.The Plandenied your request. The PlansaysMedicare will cover one pair ofglasses following cataract surgery butdoes not cover specialty IOLs implanted to correct vision.The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a conventional IOL. While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-correcting feature of an IOL.Therefore, we decided that the Plandoes not haveto pre-approveToric (astigmatism-correcting lens).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle (POV) (K0800).You asked the Plan to pre-approvea POV. You say that the item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that POVs are covered when specific criteria is 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 POV. Our reviewer says that the item is not medically necessary. Our physician reviewer found in this case, the enrollee is not noted to have inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this request is not 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 a POV have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle (POV) (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe office visit rendered to you by a chiropractor on October 16, 2019 and October 25, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered when performed by a chiropractor.The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider submitted claims for procedure code 99201 (office visit).Therefore, we decided that the Plan does not have to pay forthe office visit rendered to you by a chiropractor on October 16, 2019 and October 25, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forpost-stabilization inpatient hospital care provided September 5, 2019 to September 10, 2019.You asked the Plan to pay forthe inpatient services. You say that services were medically necessary.The Plan denied your request. The Plan says the enrollee was stable for transfer to an in-network facility.The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient services. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee was stable and appropriate for ambulance transport with monitoring and oxygen to a Plan facility for observation/admission level of care services after the emergency room evaluation on 9/5/19. There was no documentation provided necessitating post-stabilization care services at the non-plan facility.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 inpatient services have not been met.Therefore, we decided that the Plan does not have to pay forpost-stabilization inpatient hospital care provided September 5, 2019 to September 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on June 24, 2019.You asked the Plan to pay forthe dental services. You say that you went to the dentist believing that the exam and x-rays would be covered. You say that you wrote it off as a bad experience until you received the Evidence of Benefits from the Plan. You also say that the services were billed as an emergency, but you had made the appointment 2 weeks in advance.The Plan denied your request. The Plan says periapical x-rays are not a covered service.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 periapical x-rays are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe initial periapical x-ray (D0220) and the additional periapical x-ray (D0230) provided on June 24, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approveendodontic therapy (D3320) for tooth #20.You asked the Plan to pre-approvethe endodontic therapy. The Plan denied your request. The Plan says that there is significant bone loss and a poor crown to root ratio on tooth #20. The Plan also says that based on the standard of care, this finding results in a poor long-term prognosis for this tooth.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. The Plan covers the endodontic therapy when the services are medically necessary and reasonable.We asked our physician reviewer to carefully review the case file and apply therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the endodontic therapy. Our reviewer says that the service is medically necessary. Our physician reviewer found the tooth has a crown with very deep margins. Our reviewer found that it is clear that there had been previous bone loss on the distal of tooth #20, placing the crown margin very far down on the root surface. Our physician reviewer found that given the amount of bone (75% on the mesial, 50% on the distal) along with the rather bulbous root, which increases the surface area of the periodontal ligament that holds the tooth in the bone, it appears that this tooth would have a reasonably good long term prognosis. Our reviewer found that endodontic treatment to preserve this tooth would therefore be considered medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the endodontic therapy have been met.Therefore, we decided that the Plan has to pre-approveendodontic therapy (D3320) for tooth #20.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 orif 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea CT Scan of the abdomen and pelvis.You asked the Plan to pre-approvethe CT Scan. You say that the CT Scan is medically necessary.The Plan denied your request. The Plan says results of a recent ultrasound of the abdomen did not explain the problem or showed limited views.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 wascorrect in denying the request to pre-approve the CT Scan. Our reviewer says that there is no specific clinical rationale for the requested CT scan of the abdomen/pelvis. Our physician reviewer found the requested CT scan is not medically necessary and reasonable.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 CT Scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea CT Scan of the abdomen and pelvis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower/commode chair.You asked the Plan to pre-approveshower/commode chair. You say that your current chair is in a state of disrepair, and having this chair is a strong preventive measure for avoiding problems.The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this chair is not covered by Medicare.The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature.The file does not show that you are confined to a bed or room as defined by Medicare rules.Therefore, we decided that the Plan does not have to pre-approvea shower/commode chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea temporary lower denture.You asked the Planto pre-approvethe denture. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is 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.Therefore, we decided that the Plandoes not haveto pre-approvea temporary lower denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from August 14, 2019 to September 12, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan saysthe custodial care that the enrollee required from unlicensed staff is not a skilled service that is covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer saysthat the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from August 14, 2019 to September 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe treatment of a left femoral fracture (27236 AS LT) provided on November 14, 2019.You asked the Plan to payforthe treatment of a left femoral fracture. You say that this code is supported.The Plan denied your request. The Plan says the service cannot be verified and the documentation does not support that the procedure was performed on the left side.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 27326 is open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic replacement.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 treatment of a left femoral fracture. Our reviewer says that the billing of 27236 AS LT is not supported by the records. Our physician reviewer found the documentation indicates that the enrollee's right hip was affected and treated. Therefore, billing for services on the left hip is not supported.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 treatment of a left femoral fracture have not been met.Therefore, we decided that the Plan does not have to pay forthe treatment of a left femoral fracture (27236 AS LT) provided on November 14, 2019.