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

We decided that the Plan has to pay for the acute inpatient hospital care provided January 10 through January 13, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the level of care was appropriate for the member. The Plan denied your request. The Plan says that the member could have received the care they needed in an observation level at your hospital.

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 that it was medically acceptable that upon admission and throughout admission, there was expectation of hospitalization beyond two midnights. This enrollee has multiple medical problems with advanced dementia and frequent falls. She had a fall during hospitalization, and it is acceptable that there was concern about her being home without health care aids and that the hospital looked into other possible locations for discharge and physical therapy options given her risks. 

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 January 10 through January 13, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be provided by an OON oral surgeon.
You asked the Plan to pre-approve the consultation. You say that you need this service provided, and there are no participating oral surgeons within a 100 mile radius of where you live. The Plan denied your request. The Plan says the consultation with an OON provider is not medically necessary. The Plan also says that the requested service can be provided by an in-network provider.
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 covered when they are received by anyone other than a participating provider. Therefore, we decided that the Plan does not have to pre-approve a consultation to be provided by an OON oral surgeon.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion interspinous spacer.
You asked the Plan to pre-approve a Superion interspinous spacer. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not been met.
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 a Superion interspinous spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the superion device is 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 a Superion interspinous spacer have not been met. Therefore, we decided that
the Plan does not have to pre-approve a Superion interspinous spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for percutaneous vertebral augmentation (22513 and 22515)
provided on August 14, 2020.

You asked the Plan to pay for the percutaneous vertebral augmentation. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
does not support the service 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.

We asked our coder 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 percutaneous vertebral augmentation. Our reviewer says
that CPT code 22513 does not meet criteria for billing or reimbursement consideration. The medical records
provided does not include sufficient documentation to verify that a Percutaneous vertebral augmentation,
including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical
device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging
guidance; thoracic was performed on August 14, 2020, therefore, this service cannot be verified. Our reviewer
found CPT code 22515 does not meet criteria for billing or reimbursement consideration. The medical records
provided does not include sufficient documentation to confirm a Percutaneous vertebral augmentation,
including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical
device (e.g., kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging
guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary
procedure) was performed on August 14, 2020, therefore, this procedure cannot be verified.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the percutaneous vertebral augmentation have not been met. Therefore, we
decided that the Plan does not have to pay for percutaneous vertebral augmentation (22513 and 22515)
provided on August 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection without imaging guidance (62322).

You asked the Plan to pre-approve an epidural injection. You say that this is necessary because the enrollee is in pain. The Plan denied your request. The Plan says this is not covered as requested.

The Plan follows Medicare rules. Medicare rules say that standard of care for all elective (non-emergent) Epidural Injections includes image-guidance. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an epidural injection. Our reviewer says that this request does not meet the standard of care requirements. Our physician reviewer found the Standard of Care requires some form of image guidance. The procedure at issue was requested without imaging guidance. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection without imaging guidance (62322).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a core buildup, including any pins when required
(D2950).

You asked the Plan to pre-approve the core buildup. The Plan denied your request. The Plan says this service is
not covered under the enrollee's benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
core buildup, including any pins when required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI)
joint.

You asked the Plan to pre-approve RFA to the SI joint. You say that the services are necessary. The Plan
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria
have not been met.

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 RFA to the SI joint. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found RFA of the lateral sacral branches is considered experimental/ investigational
because of the wide variation in efficacy. Therefore, the request is considered 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does
not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MLH1 gene analysis.
You asked the Plan to pre-approve MLH1 gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that MLH1 gene analysis is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MLH1 gene analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve MLH1 gene analysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extractions (D7140, D7210), an implant (D6010), and
deep sedation/general anesthesia (D9223).

You asked the Plan to pre-approve extractions, an implant, and deep sedation/general anesthesia. You say that
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue
are not covered benefits.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement
of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or
paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve extractions (D7140,
D7210), an implant (D6010), and deep sedation/general anesthesia (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that you would like this service to be approved for coverage. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per 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, maxillary partial denture (D5213) is limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) on December 10, 2020 and your maxillary partial denture (D5213) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services rendered from November 24, 2020 to December 23, 2020.
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 not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had
stable vital signs in the SNF. She was treated for a skin tear. She received physical and occupational therapy
and needed contact guard to minimal assist with functional mobility, including gait to 40 feet with a walker, by
the dates in question. She needed varied assist with activities of daily living. She had no skilled nursing or
skilled therapy needs. She did not require skilled nursing or skilled therapy on a daily basis. The enrollee did
not require the necessary services on an inpatient basis at the SNF level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the skilled nursing facility (SNF) services rendered from November 24, 2020 to December 23,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 4, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the record does not include any medical records to verify why this testing was ordered. There is insufficient information to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Purewick female external catheters and urine collection accessory kits.

You asked the Plan to pre-approve Purewick female external catheters and urine collection accessory kits. You say that the items are necessary. The Plan denied your request. The Plan says the requested items are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that medical supplies of an expendable nature, such as incontinent pads, lambs wool pads, catheters, ace bandages, elastic stockings, surgical facemasks, irrigating kits, sheets, and bags are not considered "durable" within the meaning of the definition.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Purewick female external catheters and urine collection accessory kits have not been met. Therefore, we decided that the Plan does not have to pre-approve Purewick female external catheters and urine collection accessory kits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of abdomen and pelvis (74178, 78177, 74176)

You asked the Plan to pre-approve the CT scan. You say that you have been sick since 2016 and every time you eat you feel like you're going to faint. Every time you have made an appointment you've cancelled because you're too sick and you're allergic to the anesthesia. The Plan denied your request. The Plan says the requested service is not medically necessary as the provider has failed to provide supporting documentation.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.

We looked at the file and Medicare rules. In this case, a request medical records was requested from the provider. The plan has made multiple attempts to obtain the supporting documentation. The provider has failed to respond. 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-approve computed tomography (CT) scan of abdomen and pelvis (74178, 78177, 74176)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve specialist services. You say that you would feel comfortable with a female. The Plan denied your request. The Plan says there are in-network providers available 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 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 specialist services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services with DRG 190 provided on May 17, 2020, through May 22, 2020.

You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation and clinical evidence on presentation supports pneumonia as the reason for the inpatient admission.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 190. 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 hospital services. Our reviewer says that the review has determined that the documentation did not support the billing of DRG 190 for chronic obstructive pulmonary disease with MCC. Our physician reviewer found the member was initially found to be without significant wheezing and was only placed on prn breathing treatments. While the progress notes on May 20, 2020 did indicate a diagnosis of COPD exacerbation with increased wheezing and systemic steroids were added, this was 3 days after admission.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services with DRG 190 provided on May 17, 2020, through May 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the genicular nerves for the
enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is experimental and investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this is an experimental/investigational procedure that is the subject of on-going clinical trials. Therefore,
the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve radiofrequency ablation of the genicular nerves for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower overdenture and a complete upper overdenture.
You asked the Plan to pre-approve a complete lower overdenture and a complete upper overdenture. You say that the services are necessary. The Plan denied your request. The Plan says the requested 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. Therefore, we decided that the Plan does not have to pre-approve a complete lower overdenture and a complete upper overdenture.