Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81162, 81407, 81408, 81437, 81479) provided on July 29, 2020.

You asked the Plan to pay for laboratory services. You say that these codes are payable. The Plan denied your request. The Plan says these codes are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We find that CPT codes 81162, 81407, 81408, 81437, and 81479 are not supported in the medical record. Specifically, the submitted medical records do not include documentation of laboratory services. Without this information, these codes cannot be verified. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81162, 81407, 81408, 81437, 81479) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services rendered on February 25, 2021.

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 procedure code 99053 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the medical services rendered on February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because the member's current hospital plans to discharge them and they are still on a ventilator. The Plan denied your request. The Plan says the member's medical needs are being met in the current acute setting.
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 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 he is currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
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.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with rib fractures after a fall and confusion associated with chronic brain changes. She is now medically stable with no complex nursing or rehabilitation needs. She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for re-cement or re-bond fixed partial denture (D6930) provided on April 22, 2021.
You asked the Plan to pay for the dental service. You say that you were not aware that the dental office did not send in a pre-determination to determine if the claim would be paid. The Plan denied your request. The Plan says re-cement or re-bond fixed partial denture 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 dental service is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for re-cement or re-bond fixed partial denture (D6930) provided on April 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound (76813) rendered by the out-of-network (OON) provider on January 12, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the ultrasound (76813) rendered by the out-of-network (OON) provider on January 12, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a blepharoplasty, of the lower eyelid (15820), a blepharoplasty, of the upper eyelid (15822), a rhytidectomy; of the cheek, chin, and neck (15828), a reduction of the forehead (21138), augmentation of the cheek bone (21270), and a lip repair (40650).

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that The World Professional Association for Transgender Health states that these operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation.

In this case, you have gender dysphoria and are undergoing gender transition treatment. You are requesting facial feminization surgery. The records provided indicate that you are living as a woman and are taking hormonal treatment. The records submitted are sufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a blepharoplasty, of the lower eyelid (15820), a blepharoplasty, of the upper eyelid (15822), a rhytidectomy; of the cheek, chin, and neck (15828), a reduction of the forehead (21138), augmentation of the cheek bone (21270), and a lip repair (40650).

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the off-label use of this drug is not accepted.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found anaplastic lymphoma kinase (ALK) testing has not been done. Other biomarkers such as hepatocyte growth factor receptor (MET) testing should also be done. The use of this drug is not supported by any of the major drug compendia, or by any clinical research.
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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an interrogation device evaluation provided on January 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for an interrogation device evaluation. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an interrogation device evaluation provided on January 11, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns (D2740) for teeth # 25 and 26 provided on July 9,
2020.

You asked the Plan to pay for crowns for teeth # 25 and 26. You say that you had to have 4 crowns done. You
say that according to your plan, 2 of the crowns should have been covered at 30%. You also say that you do not
understand why they are being denied. The Plan denied your request. The Plan says 2 crowns are covered per
calendar year. The Plan also says that the frequency limit for this service has been exceeded.

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 and crowns are listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for crowns for teeth # 23 and 24.
Therefore, we decided that the Plan does not have to pay for the crowns (D2740) for teeth # 25 and 26 provided
on July 9, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is 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 pre-approve the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require any skilled nursing services and you do not need skilled therapy services on a daily basis at an inpatient level in a SNF. 

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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 8, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on September 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CGM system and standard supply allowance for this device (CPT code(s): K0554, K0553), for the enrollee.

You asked the Plan to pre-approve the CGM and supplies. You say that it is medically necessary based on other general symptoms and signs. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation does not indicate the enrollee is on insulin injections three (3) or more times per day or using a Medicare approved insulin pump and requires frequent adjustments of their insulin dose. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve CGM system and standard supply allowance for this device (CPT code(s): K0554, K0553), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311) and power seat elevation system (CPT code E2300).
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the accessories are not necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The seat lift does not service a primary medical purpose. The upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They are necessary when there is a medical need to control power options through the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each (CPT code E2313), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311) and power seat elevation system (CPT code E2300).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you are a major fall risk. The Plan denied your request. The Plan says you do not need an intensive team to oversee care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that you were admitted to the acute care hospital for weakness and a Coronavirus infection. Your medical problems are stable. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
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 no longer needs acute care. The Plan denied your request. The Plan says the enrollee will not benefit and improve with LTACH management.
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 the enrollee was admitted to the current acute care hospital with ileus and hematemesis. He was found to have altered mental status, was intubated, and treated for pneumonia. He appears to be currently unstable and with a poor prognosis, requiring short-term additional acute care services, which can be safely completed at the current facility. He does not require services at the LTACH that are not already available at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time would not provide a clinical advantage.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).

You asked the Plan to pre-approve the PET-CT scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria.

The Plan must follow Medicare rules. Medicare rules say that PET 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 was correct in denying the request to pre-approve the PET-CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the diagnosis of myeloproliferative disease was established at anther facility. The enrollee is not and has not been actively-being treated. A referral to a hematologist is planned. The record indicates that the enrollee has had an initial scan. The record does not indicate that the requested test is being used to plan initial therapy or to determine whether the candidate is a candidate for an invasive procedure. The elements of the coverage criteria are not satisfied. 

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 PET-CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).