Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to hold you harmless for ultrasound services provided on April 30, 2021.
You asked the Plan to pay for ultrasonic guidance for needle placement (76942) and ultrasound, soft tissues of head and neck (76536). You say that you had no choice in selecting a plan provider. The Plan denied your request. The Plan says that the claim for biopsy is paid but medical records were not provided to support the remaining services.
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 follows these rules. You were referred for ultrasonic guidance for needle placement (76942) and ultrasound, soft tissues of head and neck (76536) by a contract provider. The file does not show that the Plan provided notice that ultrasonic guidance for needle placement (76942) and ultrasound, soft tissues of head and neck (76536) would not be covered. Under Medicare rules, this means ultrasonic guidance for needle placement (76942) and ultrasound, soft tissues of head and neck (76536) is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for ultrasound services provided on April 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vertiflex superion device.
You asked the Plan to pre-approve a vertiflex superion device. You say that the Vertiflex Superion Interspinous space is FDA approved and a minimally invasive device that restores the space between the vertebrae. You say that this outpatient procedure minimizes tissue damage and blood loss, allowing for a faster and more comfortable recovery. The Plan denied your request. The Plan says there are not enough studies to show that use of the vertiflex superion device is better than regular spine surgery for the enrollee's problem.
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 vertiflex superion device. Our reviewer says that a vertiflex superion device is not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy. 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 vertiflex superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a vertiflex superion device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 power operated vehicle (POV).
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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 criteria for coverage are not met. Our physician reviewer found the enrollee has a mobility deficit that impairs the completion of mobility-related activities of daily living (MRADLs) in the home that is not helped by the use of a walker, cane, or manual wheelchair. However, the documentation does not contain a home evaluation indicating that the enrollee can safely operate a POV in the home. The criteria for coverage are not met and the item 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 Group 1 power operated vehicle (POV).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the resin based composite filling or restoration (D2391, D2393), interim complete mandibular denture (D5811), and interim partial denture (D5821), provided on July 24, 2020.
You asked the Plan to pre-approve the routine dental services. You say that the services were medically necessary. The Plan denied your request. The Plan says you have exhausted the Plan benefit for filling or restorations and the other services are not covered 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 pre-approve the resin based composite filling or restoration (D2391, D2393), interim complete mandibular denture (D5811), and interim partial denture (D5821), provided on July 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical connection (E2311) for a power wheelchair for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the electrical connection between the wheelchair and the expandable controller is not medically necessary, as an expandable controller has not been requested.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities supports that the enrollee can control any power options through their own individual switches. 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 electrical connection (E2311) for a power wheelchair for the enrollee.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and dehydration. The enrollee's medical problems are stable. 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. 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 this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel surgery.
You asked the Plan to pre-approve carpal tunnel surgery. You say that the enrollee has carpal tunnel syndrome and the surgery is medically necessary. The Plan denied your request. The Plan says the records show no evidence of the enrollee having had a nerve conduction study (NCS) and/or an electromyography (EMG) confirming the diagnosis and severity of carpal tunnel syndrome. The Plan says that the enrollee's physical exam findings are equivocal for carpal tunnel syndrome based on the CTS-6 scoring system.
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 carpal tunnel surgery. Our reviewer says that carpal tunnel surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the diagnosis has not been clearly established. Our physician reviewer found that a nerve conduction study 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 carpal tunnel surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel surgery.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. The Plan denied your request. The Plan says additional 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 pre-approve 10 additional physical therapy 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 you had prior therapy and have been approved additional therapy to ensure proper instruction in a home exercise program. Our reviewer says that the unique skills of a professional therapist are not required to safely and effectively provide ongoing treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient psychiatric admission and care from October 9, 2021, forward.
You asked the Plan to pre-approve an inpatient psychiatric admission. You say that the enrollee still has suicidal thoughts and is still in a current manic state and therefore needs inpatient treatment. The Plan denied your request. The Plan says that under Medicare guidelines, the request is not medically necessary because the records received show that the enrollee's condition has improved and she is no longer a threat to herself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 an inpatient psychiatric admission. Our reviewer says that an inpatient psychiatric admission and care from October 9, 2021, forward is not medically necessary. Our physician reviewer found that this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. Based upon review, the records provided for the admission of this enrollee do not meet the criteria for continued acute inpatient mental health treatment from October 9, 2021, forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats of safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission and care from October 9, 2021, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D7471).
You asked the Plan to pre-approve the services. You say that you want to be able to eat and gain weight back. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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 dental services (D7471).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a nerve block injection (64447) and anesthesia services (99100) provided on December 7, 2020.
You asked the Plan to pay for a nerve block injection and anesthesia services. You say that these services were authorized and billed correctly. The Plan denied your request. The Plan says these services cannot be paid as 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 64447 is injection(s), anesthetic agent(s) and/or steroid; femoral nerve. Code 99100 has a status indicator of B. We find that CPT code 64447 and 99100 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of a femoral nerve injection to support 64447. Code 99100 has a status indicator of B and is therefore not separately payable. Based on this information, we decided that Medicare rules for coverage of a nerve block injection and anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for a nerve block injection (64447) and anesthesia services (99100) provided on December 7, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound examination (76705) provided on May 28, 2021.
You asked the Plan to pay for ultrasound 76705. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because codes 76705 and 93976 have a procedure-to-procedure edit of 1 meaning that this code is only separately payable with an appropriate modifier which was not billed on this code.
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, we have confirmed that code 76705 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier, which was not billed on this code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound examination (76705) provided on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for durable medical equipment purchased on May 12, 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 the provider is not Medicare-certified.

The Plan must follow Medicare rules. Medicare rules say that services must be provided by providers who are enrolled in the Medicare program. 

The rendering provider is not eligible to bill Medicare. The Plan did not pre-approve the services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for durable medical equipment purchased on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stair/chair lift to get from one floor to another.
You asked the Plan to pre-approve the stair/chair lift. You say that you state you are in too weak of a condition to be able to move around your home without the assistance of a chair lift to get from the first floor to the second floor. You state a cane or walker is not helpful in this situation and needs the additional assistance. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Review of the file shows that you are requesting a chair lift to go upstairs. This is an item not primarily used to treat a medical purpose. You have been prescribed a walker for your unsteady gait. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve stair/chair lift to get from one floor to another.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received
from May 5, 2021, to May 10, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the only reason
why you had to stay in the hospital is because the social worker had problems finding a rehabilitation facility.
The Plan denied your request. The Plan says you were charged this copayment 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 $200
copayment per day for days 1-4 for inpatient hospital services.
You have been asked to pay a $200 copayment per day for days 1-4 for the inpatient hospital services. This
copayment applies regardless of the reason for the inpatient stay.
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 services you received from May 5, 2021,
to May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $250 copayment charged for ambulance transport provided on May 7, 2021.
You asked the Plan to waive this copayment. You say that you were told this copayment would be waived if you were admitted. The Plan denied your request. The Plan says this copayment is a contractual obligation.
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 each one-way ambulance transport. 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 $250 copayment charged for ambulance transport provided on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoride varnish application provided on April 29, 2021.
You asked the Plan to pay for the fluoride varnish application. You say that you were informed they accepted Medicare. The Plan denied your request. The Plan says the fluoride varnish application is not a covered benefit and the remaining services were paid.
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 fluoride varnish application provided on April 29, 2021.