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

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 1, 2021, to May 3, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee's care spanned 2 midnights. You also say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says the inpatient admission was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that the enrollee's acute chronic kidney injury and metabolic acidosis was primarily medication induced. The reviewer found that the enrollee responded and was expected to respond quickly to initial treatment. Therefore, the reviewer found that it was not expected that the enrollee would require hospital services that would likely cross 2 midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, the file shows that it was not expected that the enrollee would require hospital services that would likely cross 2 midnights. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 1, 2021, to May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 00670), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has a leg pain since 2019, giving the enrollee problems to walk. You state after imaging neuropathic pain that could be originated on the lumbar spine. You state the therapy and medication were not successful for the pain treatment. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed.
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869 and 00670), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on June 24, 2021.

You asked the Plan to pay for the periodic oral evaluation and periodontal maintenance. You say that you were not aware of a frequency limitation for these services, nor did you find any mention of this limitation in any of your customer documents. The Plan denied your request. The Plan says the benefit maximum for the time periods has been reached for 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. 

Though the Plan offers a dental benefit in excess of Medicare coverage, oral exams and deep cleaning maintenance are each limited to once every 6 months. The record shows that you received a periodic oral evaluation (D0120) and periodontal maintenance (D4910) on January 5, 2021 and your oral exams and deep cleaning benefits had been exhausted through July 5, 2021. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and periodontal maintenance (D4910) provided on June 24, 2021.
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for right total hip replacement. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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 you 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 IRF admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a cardiovascular disease screening (80031) provided on January 6, 2021.
You asked the Plan to pay for a cardiovascular disease screening. You say that this is a covered service. The Plan denied your request. The Plan says this exceeds the frequency limitation.
The Plan must follow Medicare rules. Medicare rules say that Medicare shall pay for Cardiovascular Disease Screening once every 60 months. We looked at the file and Medicare rules. The records show that you previously received a cardiovascular disease screening in October 2019, fewer that 60 months prior to the service at issue. Based on this information, we decided that Medicare rules for coverage of a cardiovascular disease screening have not been met. Therefore, we decided that the Plan does not have to pay for a cardiovascular disease screening (80031) provided on January 6, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021.

You asked the Plan to pay for the laboratory services. 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 a covered benefit.

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 laboratory tests at issue in this appeal were 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 provided on March 17, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0425) provided to the enrollee on February 11, 2021.
You asked the Plan to pay for the services. You say that the trip was an emergency, and would not be covered under the global payment. The Plan denied your request. The Plan says payment is not allowed for these services because the procedure was not correctly 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 the denied Healthcare Common Procedure Coding System (HCPCS) codes is: HCPCS A0425: Ground mileage, per statute mile HCPCS A0427:
Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency) We find that the denied codes are not supported in the medical record. Specifically, our coding reviewer found that the documentation supports that inpatient hospital services provided during the date of service. Therefore, this service would not be covered as it would be bundled with the hospital services. 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 ambulance services (A0425, A0425) provided to the enrollee on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain ceramic crown.

You asked the Plan to pre-approve a porcelain ceramic crown. You say that you require a crown to permanently fix your broken tooth. The Plan denied your request. The Plan says that this is not covered by the Plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a porcelain ceramic crown.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for Mycophenolate Mofetil (J7517), Prednisone (J7512), Tacrolimus (J7507) and the pharmacy supply fee (Q0511 and Q0512) provided on September 14, 2020, through October 13, 2020.

You asked the Plan to pay for the drugs and pharmacy supply fee. You say that you would like reconsideration because you follow strict Medicare guidelines which allow a 30-day supply for Cancer and Transplant medications, and a 90-day supply for respiratory medications. The Plan denied your request. The Plan says this is a duplicate claim for services billed within the same date of service range.

The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drugs and pharmacy supply fee have not been met. Specifically, the submitted documentation does not include any medical records to verify if these services were provided or if Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for Mycophenolate Mofetil (J7517), Prednisone (J7512), Tacrolimus (J7507) and the pharmacy supply fee (Q0511 and Q0512) provided on September 14, 2020, through October 13, 2020.
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 the stay is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and is currently
unstable for transfer to an 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. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. 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 they are currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (73630, L4361, 99204) provided on February 20, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services 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.

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 services. Our reviewer says that the use of codes 73630 and L4361 is not supported by the records provided. Our reviewer found that the documentation consists of several copies of the same evaluation and management service, however, each copy did not document a radiologic examination of foot, nor a walking boot given. Therefore, these services cannot be confirmed as 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 codes 73630 and L4361 have not been met. 

Additionally, the provider billed a new patient visit (99204). However, the records show that the enrollee was provided professional services from this provider within the previous 3 years. As such, it is inappropriate to bill a new patient visit for these services. Therefore, we decided that the Plan does not have to pay for the services (73630, L4361, 99204) provided on February 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar and cervical spine for the enrollee.

You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no record of contact with the doctor after a recent six-week trial of treatment that
failed to improve symptoms.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found there is no
documentation of an adequate trial and failure of conservative measures to include physical therapy.

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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve MRI of the lumbar and cervical spine for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office/outpatient visit (CPT code 99203 x 1) and
CMT; spinal, 1-2 regions (CPT code 98940 X 6) to be provided by a chiropractor.
You asked the Plan to pre-approve the services. You say that you are in a lot of pain. The Plan denied your
request. The Plan says the clinical documentation they received does not show you need spinal manipulation
for subluxation.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
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 physician reviewer
found the record indicates that you have back pain. The record includes physical examination and radiographic
reports that do not demonstrate subluxation. The elements of the coverage criteria are not satisfied. The
requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an office/outpatient visit (CPT code 99203 x 1) and CMT; spinal, 1-2 regions (CPT code
98940 X 6) to be provided by a chiropractor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show a trial and failure of the covered alternatives.
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 test strips. Our reviewer says that the requested test strips are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has been using the requested test strips but does not provide a medical rationale why the plan's preferred test strips cannot be used. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission for a revision shoulder arthroplasty for the enrollee.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee must demonstrate signs and/or symptoms severe enough to warrant the need for medical care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that in this case, the record indicates that the enrollee is scheduled for a revision shoulder arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation and subsequently converted to admission if the need arises. The elements of the coverage rule 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission for a revision shoulder arthroplasty for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral exam (D0140), impacted tooth removal (D7240), and a tooth extraction (D7210) provided by an out-of-network provider on February 24, 2021, to March 10, 2021.

You asked the Plan to pay for a limited oral exam, impacted tooth removal, and a tooth extraction. You say that you are entitled to reimbursement for dental services. The Plan denied your request. The Plan says you have already exhausted your $750 reimbursement amount.

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. The Plan covers up to $750 every year for non-Medicare covered preventive dental services and non-Medicare covered comprehensive dental services combined.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a limited oral exam, impacted tooth removal, and a tooth extraction have not been met. The full reimbursement amount of $750 has already been exhausted. Therefore, we decided that the Plan does not have to pay for a limited oral exam (D0140), impacted tooth removal (D7240), and a tooth extraction (D7210) provided by an out-of-network provider on February 24, 2021, to March 10, 2021.