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

We decided that the Plan does not have to pre-approve eyelid revision (67904, 15823) for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no material change in visual field testing on the left side.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has dermatochalasis. The record indicates that the visual changes include blurry vision, swelling and floaters. This appears to be an acute change. The record does not indicate improvement of visual field on the left with taping. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve eyelid revision (67904, 15823) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the initial periapical x-ray (D0220), and 4 additional periapical x-rays (D0230) provided on March 1, 2021.

You asked the Plan to pay for the dental services. You say that you thought these services were covered by your insurance. You say that you were not told that they would not be covered. You say that you would not have had anything done had you known. You also say that you have no money to pay this bill. The Plan denied your request. The Plan says periapical x-ray is not listed as a covered service. The Plan says the provider in this case is out of network. The Plan also says that If you see an out of network dentist, the coinsurance level will apply to the average negotiated in network fee schedule (INFS) in your area. The Plan also says you are responsible for the difference between the INFS and dentists' charged fees when visiting an out of network dentist.

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 periapical x-rays are not among those covered under this benefit. Additionally, although the comprehensive oral evaluation is listed as covered, out of network providers may bill you for any amount greater than the payment made by the Plan to the provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), the initial periapical x-ray (D0220), and 4 additional periapical x-rays (D0230) provided on March 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care for September 13, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care. You say that the services are medically necessary. The Plan denied your request. The Plan says the enrollee's condition has improved and is no longer a threat to themself or others. The Plan also says that the requested services are not medically reasonable or 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. Our reviewer says that the requested inpatient psychiatric services are not medically necessary. Our physician reviewer found based upon review the records provided it was not expected the enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any danger to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The enrollee was cooperative and compliant with medication. The reviewer found that it does not appear medically necessary and reasonable for the enrollee to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Therefore, the reviewer found that the requested inpatient psychiatric services are not medically reasonable or 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 inpatient psychiatric care have not been met. Specifically, the file shows that the enrollee can receive these services at a lower level of care. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care for September 13, 2021, forward.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a hepatobiliary system imaging procedure (78227) provided on March 29, 2021.
You asked the Plan to pay for hepatobiliary system imaging. You say that the procedure at issue was performed and documented by the provider. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of hepatobiliary system imaging have not been met.
Specifically, the Plan has documented that the services at issue for this date of service have been previously processed and paid. The claim at issue is a duplicate. Therefore, we decided that the Plan does not have to pay for a hepatobiliary system imaging procedure (78227) provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve submucosal radiofrequency ablation of the tongue base.
You asked the Plan to pre-approve submucosal radiofrequency ablation of the tongue base. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that submucosal ablation of the tongue base, radiofrequency, one or more sites is non-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 submucosal radiofrequency ablation of the tongue base. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found it is not clear this enrollee has obstructive sleep apnea. The medical records provided do not document the sleep history and symptoms. The report of the sleep study indicates the Epworth score is 0. The home sleep study showed a minimally elevated apnea-hypopnea index, and artifact may make the study inaccurate. Thus, the information provided does not support a need for the proposed treatment. In addition, there is inadequate evidence of the effectiveness of this 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 submucosal radiofrequency ablation of the tongue base have not been met. Therefore, we decided that the Plan does not have to pre-approve submucosal radiofrequency ablation of the tongue base.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99201) provided December 21, 2020.
You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial of services. You had called the Plan and spoke with a Plan representative to make sure that according to your Plan, these services are covered. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99201) provided December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on April 5, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that no one told you that this provider was out-of-network. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the there are in-network physicians available to provide these services.

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 had network providers available who could have provided the items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for physician services provided on April 5, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on April 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on April 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 28, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 services are not medically necessary. Our physician reviewer found the enrollee has bilateral osteoarthritis
of the knee. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not
show that the required drugs would be contraindicated or less effective; therefore, Durolane is 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 Durolane.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy session (90837) integrated biopsychosocial assessment (90791) provided on April 26, 2021 to May 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the psychiatric services. You say that you assumed that the Plan would treat this as an out of network charge. You are requesting the Plan have you pay for the out of network costs only and the Plan should pay the counseling center for the rest of the fee. The Plan denied your request. The Plan says the provider is a licensed mental health counselor and is not eligible to bill Medicare.

Medicare rules say that plans can require enrollees to get care from network providers. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare.

In this case, the provider is a licensed mental health counselor. Per Medicare regulations, a licensed mental health counselor is not eligible to bill Medicare for mental health services. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for individual psychotherapy session (90837) integrated biopsychosocial assessment (90791) provided on April 26, 2021 to May 17, 2021 by an out-of-network (OON) provider.
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.
You asked the Plan to pre-approve IRF care. You say that you are afraid you will not recover fully and may hurt yourself if you do not go directly to the IRF. The Plan denied your request. The Plan says the criteria for an IRF are not met. Your care needs can be met in a lower level of care.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Protext injection services.

You asked the Plan to pre-approve Protext injection services. You say that you have severe pain. You say that your doctor has recommended this type of injection to relieve the shoulder pain. The Plan denied your request. The Plan says medical studies have not proven that the requested injections services are helpful for the 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 Protext injection services. Our reviewer says that Protext injection services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is not a Food and Drug Administration (FDA) approved medication. This would be an experimental/investigational approach. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Protext injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Protext injection services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed (CPT code 0398T), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the enrollee has undergone deep brain stimulation as the enrollee's advance age increases their risk of surgical complications. The Plan denied your request. The Plan says the Medicare rules have not been met.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our physician reviewer found the review indicates that the documentation indicates that records do not show: - Documentation of Unified Parkinson's disease rating scale (UPDRS), - Medication refractory Tremor-Dominant Parkinson's disease (TDPD), defined as refractory (or intolerant) to levodopa or levodopa equivalent medications (LEDD) = 900 mg, or - Failure of deep brain stimulation. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI guided high intensity focused ultrasound (MRgFUS), stereotactic ablation lesion, intracranial for movement disorder including stereotactic navigation and frame placement when performed (CPT code 0398T), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric services.

You asked the Plan to pre-approve the inpatient psychiatric services. You say that an inpatient level of care is appropriate for the enrollee who has continually declined. The Plan denied your request. The Plan says the guidelines for coverage have not been met.

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 the inpatient psychiatric services. Our reviewer says that the criteria for coverage of inpatient psychiatric care have not been met. Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on August 27, 2021, with Schizophrenia Paranoid Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This enrollee was compliant with treatment and having no side effects to the medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. 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 the enrollee's condition or for the purpose of diagnosis. I am unable to find an individualized treatment plan however the entire record is not present. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 20, 2021 forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors being cooperative and compliant. 

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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81230, 81240, 81241, 81291) provided on April 21, 2021.

You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported by an order.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81230, 81240, 81241, 81291) provided on April 21, 2021.