Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gingival irrigation (D4921).
You asked the Plan to pre-approve gingival irrigation. You say that these services are necessary. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival irrigation (D4921).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the revascularization (37223) provided on January 22, 2021.  You asked the Plan to pay for the revscularization service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 37223 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure).  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 revscularization service. Our reviewer says that CPT code 37223 does not meet criteria for billing or reimbursement consideration. Our reviewer found the record indicates that the enrollee underwent bilateral iliac artery revascularization procedures following aorto-iliac stenting.  The record does not indicate that the enrollee underwent an initial revascularization of the iliac artery  as defined by the requested CPT code. The elements of the coverage criteria are not satisfied.  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 revscularization service have not been met. Therefore, we decided that the Plan does not have to pay for the revascularization (37223) provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine
(Tdap) (CPT code 90715) and immunization administration (CPT code 90471) provided on August 4, 2021.

You asked the Plan to pay for the services. You say that during the annual physical your doctor rendered the
tetanus shot, and you believe it should be covered. The Plan denied your request. The Plan says the services are
not covered.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The
Plan follows the same rules.

Review of the file shows that CPT code 90715 was billed with diagnosis code Z23 (Encounter for
immunization) which is not considered an appropriate diagnosis code for Tetanus vaccine as per Medicare
Benefit Policy Manual. The immunization administration code 90471 was denied because the service is not
payable when the vaccine is not covered. Therefore, we decided that the Plan does not have to pay for Tetanus,
diphtheria toxoids and acellular pertussis vaccine (Tdap) (CPT code 90715) and immunization administration
(CPT code 90471) provided on August 4, 2021.

Benefits for the services may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sleep consultation services at an out-of-network facility.
You asked the Plan to pre-approve sleep consultation services at an out-of-network facility. You say that you
are the physician that will be providing the services. The Plan denied your request. The Plan says there are innetwork
facilities available.
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
sleep consultation services at an out-of-network facility.
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 LTACH care is medically necessary for the enrollee's continued care. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to LTACH.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. 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 long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aduhelm.  You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary. The Plan denied your request. The Plan says the testing the enrollee has received is not sufficient to support this is medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Aduhelm. Our reviewer says that the records do not show that Aduhelm is medically necessary for the enrollee. Our physician reviewer found cognitive testing performed on the patient has yielded mixed results with regard to cognitive impairment and the magnetic resonance imaging (MRI) is not specifically suggestive of a diagnosis of Alzheimer's disease. The MRI is more consistent with vascular dementia.          We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.

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 the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet injections (64491, 64490, 64492).  You asked the Plan to pre-approve the facet injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that facet injections are covered for pain present for minimum of 3 months with documented failure to respond to non-invasive conservative management.  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 facet injections. Our reviewer says that the requested injections are not medically necessary. Our physician reviewer found the records provided show now documentation of conservative treatment or management.  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 facet injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet injections (64491, 64490, 64492).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral out-of-network for messenger ribonucleic acid (MRNA) genetic testing.  You asked the Plan to pre-approve the referral. You say that this testing can prognosticate the chance of disease recurrence, but also predict the benefit of chemotherapy and/or hormone therapy. The Plan denied your request. The Plan says there is a contracted laboratory available in this case.  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 out-of-network for messenger ribonucleic acid (MRNA) genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolotherapy, TENS and supplies, and a pneumatic device provided to the enrollee on August 10, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
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 services have not been met. Medicare does not cover Prolotherapy. Prolotherapy is believed to stimulate the body's ability to heal itself by injecting a natural substance that acts as an irritant and stimulates regenerative processes. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered, which is like acupuncture. The TENS device, including supplies, for neuromuscular reconditioning is not a Medicare covered benefit. Pneumatic / vasopneumatic devices can be covered only for the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. Therefore, we decided that the Plan does not have to pay for prolotherapy, TENS and supplies, and a pneumatic device provided to the enrollee on August 10, 2021
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after January 21, 2022.  You asked the Plan to pre-approve the continuation of SNF care. You say that you continue to require SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision.  Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs are custodial and, 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the services could be provided in another setting, such as acute
rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting, or home care.
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 was admitted an infected amputation site. The record indicates that the
enrollee is improving ad may be placed at an LTACH or skilled nursing facility.
The enrollee continues to receive acute care services, and these have not been denied. The medical record does
not indicate that the enrollee requires services that he is not currently receiving but that would be available at
the LTACH facility. The elements of the coverage rules 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve admission to a LTACH.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pay for an oxygen concentrator provided on July 12, 2021.  You asked the Plan to pay for oxygen concentrator. You say that your treating physician directly submitted the prescription for this device. The Plan denied your request. The Plan says that the denial of payment for this item is correct, because without records from your pulmonologist the Plan cannot determine the medical necessity of this device.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. This oxygen concentrator was ordered by your treating pulmonologist. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice that this item would not be covered. Without this information, we cannot determine whether the prescription made by your treating pulmonologist constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this item is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for an oxygen concentrator provided on July 12, 2021.   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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a partial upper denture (D5213) and a partial lower denture (D5214) provided on September 13, 2021.

You asked the Plan to pay for a partial upper denture and a partial lower denture. You say that it is not your responsibility to pay for this service. You also ask that the Plan investigate the charges. The Plan denied your request. The Plan says the frequency limitation 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. The Plan covers a partial upper denture and a partial lower denture every five years.

We looked at the file and Medicare rules. The records show that you received a partial upper denture and a partial lower denture on January 22, 2020, therefore, you have exhausted your maximum benefit for this service. Based on this information, we decided that the Plan's rules for coverage of a partial upper denture and a partial lower denture have not been met. Therefore, we decided that the Plan does not have to pay for a partial upper denture (D5213) and a partial lower denture (D5214) provided on September 13, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) during nonintracranial
surgery (95955) provided on July 20, 2021.
You asked the Plan to pay for the EEG during surgery. You say that these services were medically necessary
and referred by a network provider. The Plan denied your request. The Plan says they agree that the
neurophysiological monitoring represented by codes 95941 and 95937 are medically necessary, and these
services have been approved. However, the EEG during nonintracranial surgery, represented by code 95955,
was not medically necessary at the time of service. An intraoperative EEG would be reasonable for monitoring
cerebral function during carotid artery or intracranial vascular surgery. This is not medically necessary during
routine cervical laminectomy surgery and remains denied.
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 pay for the EEG during surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the record in this case shows that the enrollee underwent cervical discectomy. The
enrollee did not undergo intracranial or carotid artery surgery and the record does not provide a reason for
electroencephalogram monitoring. 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; the requested service is not 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 EEG during surgery have not been met. Therefore, we decided that the Plan
does not have to pay for the electroencephalogram (EEG) during nonintracranial surgery (95955) provided on
July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the laboratory services (CPT code(s): 87481, 87500,
87653, 87640) provided to the enrollee on August 31, 2021, by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the services were medically
necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not
referred by a network provider, and the services were not urgent or emergent, nor were they approved in
advance.
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 laboratory services (CPT code(s): 87481, 87500, 87653, 87640) provided to the enrollee on August 31,
2021, by an out-of-network provider.