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

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
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 fever and infection associated with a recent liver transplant. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided May 24, 2021.
You asked the Plan to pay for the limited oral exam. You say that it is important to have good dental health. The Plan denied your request. The Plan says you have exceeded frequency limits for this 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. The Plan covers the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on May 12, 2021. Based on this information, we decided that the Plan's frequency limit
for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to
pay for the limited oral evaluation - problem focused (D0140) provided May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 3, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 13, 2020.
You asked the Plan to pay for the limited oral exam. You say that this service is covered under your benefits. The Plan denied your request. The Plan says you have exceeded frequency limits for this 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. The Plan covers the limited oral exam once per plan year. We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam was previously covered on November 5, 2020. Based on this information, we decided that the Plan's frequency limit for coverage of the limited oral exam has been exceeded. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) provided November 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endocrinology office visits (CPT code 99213) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visits. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says there is no medical need shown as to why you cannot get office visits from a provider in your Health Plan network.
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 the endocrinology office visits (CPT code 99213) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) and filling (D2335) provided on May 10, 2021.

You asked the Plan to reimburse you for the dental services. You say that you should be reimbursed for these services. The Plan denied your request. The Plan says 1 periapical x-ray is covered per year. The Plan says that 2 fillings are covered per calendar year. The Plan also says that these frequency limits have 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 the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on January 4, 2021. The record shows that the Plan paid for 2 fillings that you received on January 11, 2021, and March 30, 2021. Therefore, we decided that the Plan does not have to reimburse you for the periapical x-ray (D0220) and filling (D2335) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
You asked the Plan to pre-approve sacroiliac joint radiofrequency ablation. You say that you would like
reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan
says radiofrequency neurolysis for the treatment of sacroiliac joint pain is excluded by medical journals.
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 sacroiliac joint radiofrequency ablation.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered
experimental and investigational. Radiofrequency ablation for denervation, whether performed using
traditional, cooled, or pulsed radiofrequency, is considered investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of sacroiliac joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for muscle studies and anorectal manometry provided from April 6, 2021, to May 18, 2021.

You asked the Plan to waive the copayments for muscle studies and anorectal manometry. You say that your father received the same procedure in the past and did not owe anything. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $40 copayment for specialist services. Your contract with the Plan also clearly says that you must a $10 copayment for outpatient diagnostic procedures and tests.

You received a muscle study and anorectal manometry on April 6, 2021. Therefore, you are responsible to pay a $40 copayment for the muscle study and a $10 copayment for anorectal manometry. The total amount you owe is: $50. 

You received a muscle study and anorectal manometry on April 20, 2021. Therefore, you are responsible to pay a $40 copayment for the muscle study and a $10 copayment for anorectal manometry. The total amount you owe is: $50. 

You received a muscle study and anorectal manometry on May 4, 2021. Therefore, you are responsible to pay a $40 copayment for the muscle study and a $10 copayment for anorectal manometry. The total amount you owe is: $50. 

You received a muscle study and anorectal manometry on May 11, 2021. Therefore, you are responsible to pay a $40 copayment for the muscle study and a $10 copayment for anorectal manometry. The total amount you owe is: $50. 

You received a muscle study and anorectal manometry on May 18, 2021. Therefore, you are responsible to pay a $40 copayment for the muscle study and a $10 copayment for anorectal manometry. The total amount you owe is: $50. 

The total amount you owe is: $250. 

You have been asked to pay the total copayment amount of $250 for muscle studies and anorectal manometry. Muscle studies fall within the physician/practitioner services, including doctor's office visits benefit category. Anorectal manometry falls within the outpatient diagnostic tests and therapeutic services and supplies 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 copayments for muscle studies and anorectal manometry provided from April 6, 2021, to May 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (85018, 83036, 82926, 80048 and
0202U), prescription drugs (J8499) and non-covered services (A9270) provided on August 7, 2020, through
August 11, 2020.

You asked the Plan to pay for the laboratory services, prescription drugs and non-covered services.. You say
that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan
says the billed services are non-covered in this setting.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The
rules also say that screening tests are excluded from coverage.

We find that CPT codes A9270, J8499, 85018, 83036, 82926, 80048 and 0202U are not supported in the
medical record. Specifically, this claim has been billed with a diagnosis code for screening. Screening services
are excluded from coverage. Additionally, per Medicare, CPT codes A9270 and J8499 are non-covered. Based
on this information, we decided that Medicare rules for coverage of the laboratory services, prescription drugs
and non-covered services. have not been met. Therefore, we decided that the Plan does not have to pay for the
laboratory services (85018, 83036, 82926, 80048 and 0202U), prescription drugs (J8499) and non-covered
services (A9270) provided on August 7, 2020, through August 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve skilled nursing facility services. You say that you are very weak from being in the hospital and cannot stand. The Plan denied your request. The Plan says you do not have daily skilled nursing needs.

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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of 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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.
You asked the Plan to pre-approve the ventilator. You say that this oxygen concentration needs to be covered. The Plan denied your request. The Plan says the enrollee does not meet the acceptable blood gas level appropriate for coverage.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found that according to this NCD, this service is covered when you have an oxygen level at rest which is at or below 88% breathing room air. The record shows that the enrollee's oxygen level was 95% breathing room air. The patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease.
The documentation in the medical record does not support that the ventilator at issue is medically necessary and reasonable for this patient. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an auricular stimulator.
You asked the Plan to provide implantable neurostimulator, pulse generator, any type (L8679) and
percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555).
You say that you need the unit to help with chronic pain and reduce the use of narcotics. The Plan denied your
request. The Plan says this device 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. This device is not covered by Medicare. Based on this information,
we decided that Medicare rules for coverage of implantable neurostimulator, pulse generator, any type (L8679)
and percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
(64555) have not been met. Therefore, we decided that the Plan does not have to provide an auricular
stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99233) provided on September 8, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the allowed units has been exceeded.

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 99233 is "Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit". 

We find that an additional unit of CPT code 99233 is not supported in the medical record. Specifically, the definition of code 99233 indicates that this is a per diem service, which means that billing this code more than once on the same date of service would be inappropriate. 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 the services (99233) provided on September 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the two crowns (D2750 x2).
You asked the Plan to pre-approve the crowns. You say that you went to the dentist on June 3, 2021 and they
sent information to the Plan, but the provider still has not received anything back for you to receive these
procedures. The Plan denied your request. The Plan says this service is not covered under your benefit 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 the
two crowns (D2750 x2).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 27, 2021.
You asked the Plan to pay for the testing services. You say that the ordering physician attested to the Medicare coverage criteria. The Plan denied your request. The Plan says there is no written order to confirm the requirement of the genetic testing.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing is only covered under certain medical indications.
We looked at the file and the rules. We find that the testing services at issue in this appeal are not supported in the medical record. Specifically, the records do not show that tissue-based comprehensive genomic profile (CGP) testing was infeasible or that tissue-based CGP showed no actional mutations. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on February 27, 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(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says more studies are needed to show Vertiflex is safe and effective.

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 enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multi-level disease including mild spinal stenosis at L3-L4 and L4-L5 levels, the levels requested for treatment. The provided record does not state that the enrollee is not indicated for operative intervention at more than two levels. 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 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(s): 22869 and 22870), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999)
provided on December 7, 2020.
You asked the Plan to pay for the personal protective equipment (PPE). You say that the provider was listed as
in-network. The Plan denied your request. The Plan says a one-time exception was made for the services
provided on this date to be reprocessed as in-network, however this service is not covered under your benefits.
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 the
unspecified preventive procedure, by report (D1999) provided on December 7, 2020.