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

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the
head/brain.
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 not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a PET scan is covered when specific criteria are
met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have a
history of seizures and possible stroke. You recently suffered a fall with a resulting concussion. The records do
not show that you have a diagnosis of dementia. The PET scan is not being requested to differentiate between
Alzheimer's dementia and frontotemporal dementia. The PET scan is therefore not reasonable or medically
necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a positron emission tomography (PET) scan of the head/brain.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for six (6) additional physical therapy (PT) visits.
You asked the Plan to pay for additional PT visits. You say that additional PT visits are medically necessary. The Plan denied your request. The Plan says six (6) additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 six (6) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy of 24 outpatient visits and approved for 6 more additional visits for a total of 30 visits. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee should be able to transition to a home exercise program with the approved therapy visits. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of six (6) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pay for six (6) additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power options (K0862), battery (E2361), power seat tilt/recline (E1007), swingaway joystick mount, headrest mounting hardware, removable mounting hardware (E1028), plush head support headrest (E0955), power functions through joystick (E2311), expandable controller upgrade (E2377), access harness upgrade (E2313), seat cushion (E2607), power center mount (E1012), and lateral thigh pads (E0956).
You asked the Plan to pre-approve a group 3 PWC with multiple power options and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says as the group 3 pwc with multiple power options is not reasonable and necessary, none of the requested accessories can be covered.
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 group 3 PWC with multiple power options and accessories. Our physician reviewer found the requested group 3 PWC with multiple power options is not medically reasonable and necessary. Our physician reviewer also found that the member is not at risk for development of a pressure ulcer and has no current history of pressure ulcers. 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 group 3 PWC and accessories have not been met. Specifically, the member does not meet the criteria for a group 3 PWC with multiple power options. This also means that all requested accessories are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (PWC) with multiple power options (K0862), battery (E2361), power seat tilt/recline (E1007), swingaway joystick mount, headrest mounting hardware, removable mounting hardware (E1028), plush head support headrest (E0955), power functions through joystick (E2311), expandable controller upgrade (E2377), access harness upgrade (E2313), seat cushion (E2607), power center mount (E1012), and lateral thigh pads (E0956).
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 need IRF care. The Plan denied your request. The Plan says you do not need an intense team approach to rehabilitation.
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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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. 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 pre-approve a porcelain fused to high noble metal crown (D2750) for
tooth # 24.
You asked the Plan to pre-approve the dental service. You say that you had a root canal in December 2020.
You say that your crown broke in May 2021. You also say that the dentist office advised that they could fix the
crown, but that insurance would not cover it. The Plan denied your request. The Plan says crowns are covered
once per tooth every 5 plan years. The Plan also says that the frequency limit has been reached.
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 the crown is listed as covered, the
frequency limit has been reached. The record shows that the Plan paid for a crown for tooth # 24 that you
received on December 4, 2020. Therefore, we decided that the Plan does not have to pre-approve a porcelain
fused to high noble metal crown (D2750) for tooth # 24.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says services must be provided by 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. 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 provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 28 to May 29, 2020.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you had Medicaid coverage for the dates in question. The Plan denied your request. The Plan says the correct copayment was applied.
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 $393 copayment for each day for days 1 to 5 for inpatient hospital care.
You have been asked to pay a $393 copayment for a one-night stay for inpatient hospital care. 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 inpatient hospital care provided on May 28 to May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy with biopsy provided
March 2, 2020.
You asked the Plan to waive the copayment for the colonoscopy with biopsy. You say that you were not aware
that this service would be billed with a copayment. The Plan denied your request. The Plan says the claim
processed correctly.
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 $250
copayment for Medicare-covered outpatient surgical services.
You have been asked to pay a $250 copayment for the colonoscopy with biopsy. This service falls within the
Medicare-covered outpatient surgical 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 colonoscopy with biopsy provided March 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the creation of sling around bladder canal
to control leakage (57288) provided on September 1, 2020.
You asked the Plan to waive the coinsurance for the creation of sling around bladder canal to control leakage.
You say that you were unaware you would be charged for this procedure. The Plan denied your request. The
Plan says the coinsurance has processed correctly in this case.
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 20%
coinsurance for outpatient hospital services.
You have been asked to pay a total cost share of $783.83 for the creation of sling around bladder canal to
control leakage ($3,919.14 Medicare allowed amount x 20% coinsurance). This service falls within the
outpatient hospital 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 coinsurance for the
creation of sling around bladder canal to control leakage (57288) provided on September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic Assay rendered on October 20, 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. Medicare rules say that pharmacogenetic testing is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of generalized anxiety disorder. The provider notes on the GeneSight Order Medical Necessity Documentation form that amitriptyline, alprazolam, paroxetine, and trazodone have failed to work for this enrollee, and that he is considering augmenting therapy with a new medication, or starting/switching to a new medication. The case file does not contain clinical medical records. There is no documentation of what drug(s) is/are being considered, to ensure that the test performed is reasonable and necessary. The testing was therefore not reasonable or medically necessary for the enrollee. 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 GeneSight Psychotropic Assay rendered on October 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical boot.
You asked the Plan to pre-approve the requested boot. You say that you are having difficulty walking without a boot. The Plan denied your request. The Plan says the surgical boot is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The requested boot is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve a surgical boot.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (CPT 70486) provided to the enrollee on
January 28, 2021.
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 use of routine diagnostic imaging is not recommended for patients with allergic rhinitis because
there are no specific findings for confirming the diagnosis.
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 70486 is "computed tomography, maxillofacial area;
without contrast material."
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 the
enrollee had a CT scan performed for diagnosis "allergic rhinitis". Typically, a CT scan is not medically
necessary or reasonable for allergic rhinitis. Academy of Otolaryngology does not support the use of imaging
to diagnose allergic rhinitis. Allergic rhinitis can be diagnosed based on clinical symptoms, physical exam
findings, and diagnostic testing such as allergy testing. Allergic rhinitis was not an appropriate diagnosis for
this scan.
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 radiology services (CPT 70486) provided to the enrollee on January 28, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee has
not met the step therapy requirements.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Synvisc-One. Our reviewer says that
Synvisc-One is not medically reasonable and necessary in this case. Our physician reviewer found that the
enrollee is noted to have osteoarthritis. The health plan requires that other forms of hyaluronic acid injections
be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic
acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid
injections. There is no documentation as to why these other forms of hyaluronic acid would not be expected to
be safe and effective for the enrollee. Therefore, the requested Synvisc-One is not shown to be currently
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 Synvisc-One have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-One.
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 you are well enough to be moved and
need additional care to build strength in order to return home. The Plan denied your request. The Plan says an
LTACH is not medically necessary. You do not require extensive or complex wound care management by
skilled nursing of at least 6.5 hours per day. Additionally, the wound care does not require daily intervention by
a physician. Criteria for admission to the LTACH have not been met. Your medical needs are being met in the
current acute setting. The LTACH would add no additional services.
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 that there is no documentation provided necessitating admission to an LTACH. You
are receiving appropriate care at the present acute care hospital You do not require services at the LTACH that
are not available at the acute care hospital where you are currently receiving care. The requested LTACH
services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and the
necessary care is able to be furnished safely and effectively in the current 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive genetic panel (81225, 81226, 81227,
81230, 81231, 81240, 81241, 81291, 81328, 81401) provided on July 27, 2020.
You asked the Plan to pay for a comprehensive genetic panel. You say that this service was provided in good
faith. The Plan denied your request. The Plan says this is not a covered service.
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, a comprehensive genetic panel, was performed 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 a comprehensive genetic panel (81225, 81226, 81227, 81230, 81231, 81240, 81241, 81291,
81328, 81401) provided on July 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on July 11, 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 the records do not support the services 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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." We asked our coding 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 coding reviewer found the documentation was carefully reviewed, and no therapist visit was found to support the claim as reported. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on July 11, 2020.