Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve image guidance for balloon sinuplasty and removal or destruction within the nose (CPT 61782, CPT 30117)
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not considered standard of care.
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 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 considered medically reasonable and necessary in this case. Our physician reviewer found CPT code 31276 and CPT code 31257 were reviewed and approved by the plan. CPT code 61782 is used for stereotactic navigation during a sinus procedure, such as sinus surgery. This is considered standard of care in any sinus surgery, but especially in surgery that involves the ethmoid sinuses. The ethmoid sinuses are bordered by the eye and by the skull base, which means it's especially important to track the instruments to the CT scan while operating. Otherwise rare but dangerous complications can occur. CPT code 30117 is for clarifix. The enrollee has a clear diagnosis of vasomotor rhinitis (VM). She has the symptoms of VM and she responded appropriately to medical management. She would benefit from a surgical procedure to the vidian nerve to reduce her symptoms and help manage her condition. The evidence is limited because this is a new device. However the evidence behind addressing the vidian nerve is well established and procedures to address this nerve have been done since the 1960's. Ablating the vidian nerve is not experimental and is actually considered the standard of care for surgical treatment of vasomotor rhinitis. How the ablation is done should be determined by the surgeon performing the procedure. 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 been met. Therefore, we decided that the Plan has to pre-approve image guidance for balloon sinuplasty and removal or destruction within the nose (CPT 61782, CPT 30117)
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet light therapy system.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the requested service is to treat depression. The medical record does not indicate a diagnosis of intractable psoriasis. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet light therapy system.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on August 31, 2020.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were not notified there would be a charge for the ambulance. The Plan denied your request. The Plan says you have been asked to pay 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 $210 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $210 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance Services" 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 ambulance ride provided on August 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay you for the bitewing x-ray (D0274) provided on December 28, 2020.
You asked the Plan to pay you for the dental service. You say that your booklet clearly states that 2 oral exams, 2 cleanings, 1 dental x-ray, and 1 fluoride treatment is covered every year. You say that the provider was in network. You say that these all fall within the guidelines for coverage. The Plan denied your request. The Plan says bitewing x-ray is not listed as 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay you for the bitewing x-ray (D0274) provided on December 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated wheelchair for the enrollee.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not required for ambulation within the home.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee
does not have a personal mobility deficit that impairs participation in MRADLs in the home. The enrollee is
independent in most MRADLs. She is able to ambulate with a cane and has a four wheeled walker. The
physician medical progress notes do not support that she is unable to use an assistive device safely and
effectively. While she may have the ability to safely operate a PMD in the home the documentation does not
support that this requested power mobility device will significantly improve the enrollee's ability to participate
in MRADLs in the home.

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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power operated wheelchair for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 9, 2020, to December 8, 2020.
You asked the Plan to pay for the 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 says these 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 the skilled nursing services. Our reviewer says that 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 for the skilled nursing services provided from November 9, 2020, to December 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says a lower level of care such as outpatient treatment is more appropriate.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you were not shown to be a danger to yourself or others. You did not have any auditory or visual hallucinations. You were cooperative and compliant with treatment. You were showing poor failure to thrive, suspicious behavior, and were unable to care for yourself. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hemodialysis procedure coded 90937 provided on October 5, 2020.
You asked the Plan to pay for the hemodialysis procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 90937 is hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription. We find that CPT code 90937 is not supported in the medical record. Specifically, the documentation submitted indicates that the enrollee is on hemodialysis; however, did not include documentation of repeated evaluation with or without substantial revision of dialysis prescription performed during hemodialysis; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the hemodialysis procedure have not been met. Therefore, we decided that the Plan does not have to pay for the hemodialysis procedure coded 90937 provided on October 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network neurologist.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.

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. The Plan confirmed they have tertiary-care level providers available that provide the same level of care as the requested provider. 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 a referral to an out-of-network neurologist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380) received December 16, 2020.
You asked the Plan to pay for cone beam CT image capture. You say that this service was necessary to determine if you needed a root canal. The Plan denied your request. The Plan says the requested service is not covered under your supplemental 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 pay for cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380) received December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services (CPT 64494, CPT 64495) provided to the enrollee on September 15, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says only one unit supported per MUE.
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 the denied codes is: CPT 64494: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral CPT 64495: Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 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. Our physician reviewer found that in this case, the record indicates that bilateral four lumbar level injections were performed. The medical record does not provide any documentation of why multiple units of service are necessary for the date of service.
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 pay for injection services (CPT 64494, CPT 64495) provided to the enrollee on September 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental surgery procedure (41899), anesthesia for intraoral procedures (00170), office consultation (99245), hospital exam/treatment room (Z7500), and first subsequent half hour (Z7508) to be provided by an OON provider.

You asked the Plan to pre-approve the dental surgery procedure, anesthesia for intraoral procedures, office consultation, hospital exam/treatment room, and first subsequent half hour. You say that the enrollee requires general anesthesia for care. The Plan denied your request. The Plan says these services are not medically necessary. The Plan also says that you would like an OON provider to render 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 a dental surgery procedure (41899), anesthesia for intraoral procedures (00170), office consultation (99245), hospital exam/treatment room (Z7500), and first subsequent half hour (Z7508) to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 23, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that this exam was necessary. The Plan denied your request. The Plan says this procedure is limited to twice per calendar year. The Plan also says that you had already received two oral exams.
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 two oral examinations per calendar year. The record shows that you received oral examinations on March 5, 2020, and September 16, 2020 and your oral examinations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 23, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 16, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) and the periodic oral evaluation
(D0120) received December 21, 2020.

You asked the Plan to pay for the cleaning and oral exam. You say that you thought the cleaning and exam
would have $0 copayments. The Plan denied your request. The Plan says once the $1,000 maximum benefit
limit is met, there are no additional benefits payable through the supplemental coverage.

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 payment is in excess of
that covered under this benefit. The Plan has submitted evidence that you exhausted your $1,000 maximum
prior to this date of service. Therefore, we decided that the Plan does not have to pay for the prophylaxis
(D1110) and the periodic oral evaluation (D0120) received December 21, 2020.