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

We decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065).
You asked the Plan to pre-approve a breath hydrogen or methane test. You say that you have had chronic problems for over 20 years with no resolution. You say that you want this taken care of and feel that this denial is not right. You also say that this is medically necessary. The Plan denied your request. The Plan says that the requested service is not covered for diagnosing small bowel bacterial overgrowth (SIBO).
The Plan must follow Medicare rules. Medicare rules say that lactulose breath hydrogen test for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a breath hydrogen or methane test have not been met. Specifically, the file shows that the test is being requested to diagnose small bowel bacterial overgrowth (SIBO). This service is not covered for diagnosing SIBO. Therefore, we decided that the Plan does not have to pre-approve a breath hydrogen or methane test (91065).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Feraheme (Q0138).
You asked the Plan to pre-approve Feraheme. You say that this requested drug is medically necessary. The Plan denied your request. The Plan says that the drug is not covered for the enrollee's condition.
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 Feraheme. Our reviewer says that the requested drug is medically necessary and reasonable. Our physician reviewer found Feraheme is approved by the Food and Drug Administration for the treatment of iron-deficiency anemia in adults with an intolerance or unsatisfactory response to oral iron or who have chronic kidney disease. The elderly have issues with absorption of oral iron and IV iron is often used. Given low iron saturation and deceasing mean corpuscular volume, IV iron with Feraheme is reasonable and 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 Feraheme have been met. Therefore, we decided that the Plan has to pre-approve Feraheme (Q0138).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fixed partial denture sectioning (D9120) for teeth # 8
and 9.
You asked the Plan to pre-approve the fixed partial denture sectioning. You say that you need these services
approved for coverage in order to remain stable, strong, and healthy. The Plan denied your request. The Plan
says this service is 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 fixed
partial denture sectioning (D9120) for teeth # 8 and 9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SPG block (CPT code 64999), for the enrollee.
You asked the Plan to pre-approve the SPG block. You say that the next step in treatment for the enrollee's current status migrainosus would be to give the enrollee SPG blocks which they have received in the past with good relief. The Plan denied your request. The Plan says medical studies have not proven that the service(s) or procedure(s) is helpful for treatment of the enrollee's health 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 the SPG block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current consensus is that further study is needed. Nor have studies been undertaken to show that the requested procedure is as effective as (or more effective) compared to other procedures. In that regard, the service would be experimental/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 the SPG block have not been met. Therefore, we decided that the Plan does not have to pre-approve SPG block (CPT code 64999), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life2000 portable system.
You asked the Plan to pre-approve a Life2000 portable system. You say that the requested device is ambulatory and is able to provide portable non-invasive ventilation support for the enrollee. You say that a Bi-level positive airway pressure (BiPAP) ventilator cannot offer this capability. You say that the requested ventilator is approved by the Food and Drug Administration (FDA). You say that the requested ventilation system has the ability to provide positive pressure ventilatory support with nasal pillows which will allow her to remain
mobile in and outside of her home and carry out more activities of daily living, which in turn maintains and improves pulmonary function. The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for coverage of the requested device.
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. 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 Life2000 portable system. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the Life2000 portable system is not medically necessary. This system is not a ventilator. It is a portable device that delivers positive pressure oxygen via nasal canula during activity. There is no convincing evidence that this device is beneficial in chronic obstructive pulmonary disease (COPD), or any other lung disease. Moreover, the enrollee does not meet criteria for a home ventilator. The enrollee does not have COPD, and there is no evidence of carbon dioxide (CO2) retention. The forced expiratory volume (FEV1) and total lung capacity are normal. 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 Life2000 portable system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life2000 portable system.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99255) provided on April 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code 99255 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these 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 the services (99255) provided on April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office consultation for a new or established patient
(99244) to be provided by an OON provider.
You asked the Plan to pre-approve the office consultation. You say that there is a relationship between the
provider and the enrollee. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 office consultation for a new or established patient (99244) to be provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan says that the services required can safely be received at a different setting.
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 SNF 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. The enrollee is ambulating household distances. 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (90785) provided to you from March 9, 2020, to March 15, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the add-on code was not billed with an appropriate primary procedure 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 90785 is an add-on code and has not been billed with an appropriate primary procedure 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 the services (90785) provided to you from March 9, 2020, to March 15, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services you
received from May 24, 2021, to June 15, 2021.
You asked the Plan to waive the copayments for the PT services. You say that you were not aware there would
be a copayment for these services. The Plan denied your request. The Plan says you were charged these
copayments 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 $10
copayment per visit for physical therapy services.
Records show that you had 4 PT sessions. You have been asked to pay a $10 copayment per visit for each of
the PT services, for a total of $40. 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 physical therapy
(PT) services you received from May 24, 2021, to June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve the mandibular partial denture. You say that you have been a patient of this OON provider for many years. You also say that this OON provider has tried to become a network provider but is unable to. The Plan denied your request. The Plan says the provider you are requesting to receive this service from is an OON provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) to be rendered by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), power seat elevation device (E2300) and flip up armrest (K0108).
You asked the Plan to pre-approve an expandable controller, power seat elevation device, and flip up armrest. You say that these items are medically necessary. The Plan denied your request. The Plan says the coverage criteria for the requested items 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. The rules also say that a power seat elevation feature is statutorily noncovered. The rules also say that an expandable controller is subject to the criteria listed in the Medicare rules section. The flip up armrests at issue in this appeal do 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. In addition, the power seat elevation feature is statutorily noncovered by Medicare.
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 for the expandable controller. Our reviewer says that the requested equipment is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets Medicare criteria for the requested expandable controller and accessories (E2377, E2313, E2311). Provided records document that the enrollee has 5/5 bilateral hand strength and is independent with feeding, bathing and dressing thus indicating adequate upper extremity strength and function to control the wheelchair's power options with their own switches.
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), power seat elevation device (E2300) and flip up armrest (K0108).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from February 13, 2021, to February 28, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you were never told that any copayments would be required and you feel as though the copay is an exorbitant amount. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility services. Records show that for the claim in question (just dates of service February 13, 2021, to February 28, 2021), you
were in the SNF for 16 days. However, you had another SNF claim for dates of service March 17, 2021, to March 28, 2021 (11 days), that actually processed prior to the claim for the February dates in question. You were charged a $0 copayment for the 11 days of the March 17, 2021, to March 28, 2021, stay, since that is the first claim that processed. Then, when the claim for February 13, 2021, to February 28, 2021, processed (16 days), 9 of these 16 days had a $0 copayment. The remaining 7 days of this stay were charged a $184 copayment per day, for a total of $1288. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services you received from February 13, 2021, to February 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 8, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 8, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
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 inpatient psychiatric care from November 8, 2021, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 8, 2021, forward. Our physician reviewer found you do not require inpatient mental health treatment beyond November 8, 2021, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 8, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 8, 2021, forward.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (73560) provided on July 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the 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. In this case, we have confirmed that code 73560
is a column II code to column I code 73562. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (73560) provided on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the ventilator is necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator with settings that could be delivered by bilevel positive airway pressure (BiPAP) with average volume assured pressure support (AVAPS) for this enrollee with chronic obstructive pulmonary disease (COPD) is not covered.
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 home ventilator. Our physician reviewer found the record indicates that the plan has conceded that the enrollee has chronic respiratory failure
from chronic obstructive pulmonary disease. The record indicates that the enrollee is being treated with settings that could be administered using BiPAP with AVAPS setting. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The plan has indicated such a device is covered. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the group psychotherapy visits provided on February 1, 2021, to February 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the group psychotherapy visits. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the group psychotherapy visits provided on February 1, 2021, to February 16, 2021, by an out-of-network (OON) provider.