Persius/hicric huggingface dataset:
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 the enrollee needs LTACH care. The
Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 are no required medical services at the LTACH that are not available at the
current acute care hospital setting where the enrollee is receiving care. Consequently, the requested LTACH
services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee
at this time.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean extra heavy-duty manual wheelchair.You asked the Plan to pre-approvean extra heavy-duty manual wheelchair. You say that the enrollee needs a manual wheelchair to transfer from the car to the facilities for treatments.The Plan denied your request. The Plan says additional wheelchairs are not considered medically necessary.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that the enrollee has a power wheelchair received in 2018. Thepower wheelchair serves the same purpose as an extra heavy-duty manual wheelchair.Therefore, we decided that the Plan does not have to pre-approvean extra heavy-duty manual wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-complete series of radiographic images (D0210), adult cleaning (D1110), total application of fluoride varnish (D1206), and the extraction-erupted tooth (D7140) provided January 21, 2020 to January 29, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the dental services provided are not covered because they were rendered by an out of network dental provider. In-network dental providers are available to render these 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. We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Specifically, the dental services were provided by an out of network dental provider. The Plan contract states that care rendered by a provider that is not part of the supplemental dental network is not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-complete series of radiographic images (D0210), adult cleaning (D1110), total application of fluoride varnish (D1206), and the extraction-erupted tooth (D7140) provided January 21, 2020 to January 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forperiodontal scaling and root planing (D4341), the localized delivery of antimicrobial agents (D4381), and nitrous oxide/analgesia (D9230) provided by an out-of-network provider on January 31, 2020.You asked the Plan to pay forperiodontal scaling and root planing, the localized delivery of antimicrobial agents, and nitrous oxide/analgesia. You say that this must have been coded incorrectly.The Plan denied your request. The Plan says this processed correctly according to your 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 localized delivery of antimicrobial agents and nitrous oxide/analgesia are not among those covered under this benefit. While the Plan covers periodontic services such as periodontal scaling and root planning, there is cost-sharing associated with this service. First, you are responsible for the difference ($126) between what the out-of-network provider billed ($312) and the Plan's allowed amount, ($186). You are also responsible for a $100 deductible and a 50% coinsurance of the remaining amount (50% x $86= $43) for a total responsibility of $269. This means you have been asked to pay the correct amount according to your contract with the Plan. Therefore, we decided that the Plan does not have to pay forperiodontal scaling and root planing (D4341), the localized delivery of antimicrobial agents (D4381), and nitrous oxide/analgesia (D9230) provided by an out-of-network provider on January 31, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Planto pre-approveSNF services. You say that the enrollee needs to continue therapy so she does not have a decline in her therapy progression.The Plan denied your request. The Plan says that this patient would be equally well served at an alternative level of care.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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
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 the enrollee will require additional time to transition from acute illness. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
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 physician reviewer found that LTACHs are certified as acute care hospitals, and in general, do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include respiratory support with oxygen supplementation and tracheostomy care, mental status monitoring, surveillance laboratory studies, close fluid balance, tube feedings, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 inpatient mental health treatment.
You asked the Plan to pre-approve inpatient mental health treatment. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 inpatient mental health treatment. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on review of the records provided, you do not meet criteria for acute inpatient mental health treatment as you were not shown to be a danger to yourself or others and were not experiencing any auditory or visual hallucinations. You are noted to be cooperative and compliant with treatment while not showing any aggressive behaviors. 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 mental health treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).You asked the Plan to pre-approve Vertiflex procedure. You say that the enrollee meets the criteria for this procedure.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex has not been proven to be beneficial for the enrollee's condition.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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental, more research is needed to show its 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 Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrodesis (22532, 22614 and 22534) provided on October 23, 2019.
You asked the Plan to pay for the arthrodesis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records do not support the units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 22532 arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic. The CPT Code Manual definition of code 22614 is arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 22534 is arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure). 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 arthrodesis. Our reviewer says that CPT codes 22532, 22614 and 22534 do not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report did not include documentation that these services were performed. 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 arthrodesis have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis (22532, 22614 and 22534) provided on October 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee needs to be admitted to the LTACH.The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.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 physicianreviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically reasonable, necessary, and appropriate for the diagnosis and condition of the enrollee at this time.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology consultations (88333 and 88334) provided on May 17, 2019.
You asked the Plan to pay for the pathology consultations. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says these codes were billed with column I codes 88173 and 88172.
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, we have confirmed that codes the pathology consultations have a bundled relationship with codes 88173 and 88172 and cannot be paid as billed. These codes cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the pathology consultations (88333 and 88334) provided on May 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for incision and drainage of pilonidal cyst (10081) provided on January 10, 2020.You asked the Plan to pay for the incision and drainage of pilonidal cyst. You say that you would like reconsideration because this claim was coded correctly.The Plan denied your request. The Plan says the documentation submitted indicate that incision and drainage of pilonidal cyst; simple was performed.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 10081 is incision and drainage of pilonidal cyst; complicated.We find that CPT code 10081 is not supported in the record. Specifically, the record clearly states that the extent of the procedure was simple with no complications. There is a more appropriate CPT code that should be billed for this service. Based on this information, we decided that Medicare rules for coverage of theincision and drainage of pilonidal cyst have not been met.Therefore, we decided that the Plan does not have to pay forincision and drainage of pilonidal cyst (10081) provided on January 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gamunex-C (J1561).
You asked the Plan to pre-approve Gamunex-C. You say that the medication is necessary. The Plan denied
your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Gamunex-C. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found intravenous immunoglobulin (IVIG) is
not currently approved for use in autoimmune epilepsy. Nor is there support for the use of IVIG in autoimmune
epilepsy in the adult population within the Medicare accepted Compendia. The body of literature available on
the use of IVIG in autoimmune epilepsies is largely limited to those patients in whom a causative antibody has
been identified. In this case there was no documentation of any laboratory results that confirmed the presence
of an antibody. Consequently, it cannot be said that the use of IVIG would be medically reasonable and
necessary for the enrollee. Nor can conclusions be made on the safety of the requested medication in the
member's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gamunex-C have not been met. Therefore, we decided that the Plan does not
have to pre-approve Gamunex-C (J1561).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on January 18, 2020.You asked the Planto pay forthe testing. You say that this should be paid for.The Plandenied your request. The PlansaysComprehensive Genomic Profile (CGP) testing requires use of CPT 81479.The Plan must follow Medicare rules. Medicare rules say that services must be reported with the appropriate code. We find that the various denied CPT codes arenot supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on January 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that inpatient rehab level of intensive therapy exceeds the member's need.
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. The complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no complex wound care needs and no documentation of other complex medical needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. Although the patient does have a documented need for physical and occupational therapy, the submitted documentation does not support a need for intensive rehabilitation. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on
March 3, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you are appealing this
claim. You say you would like to know why the claim denied. The Plan denied your request. The Plan says the
claim has been reprocessed and you have been charged the correct cost sharing amount.
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 $90
copayment for emergency services at an in-network emergency room.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
within the "Emergency care" benefit category. 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 copayment for the
emergency room visit provided on March 3, 2020.