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

We decided that the Plan does not have to pay for the presumptive (80307) and definitive (G0481) drug testing provided on June 7, 2022.

You asked the Plan to pay for the drug testing. The Plan denied your request. The Plan says this is not medically necessary.

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 drug testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided records did not show abnormal or unexpected results from urine drug screening to justify confirmation/definitive testing which should be reserved for following up on unexpected drug screening results or suspicious history and only should include drug classes that are applicable to the case rather than more comprehensive testing. Therefore, this request for presumptive and definitive drug testing will be considered not 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 the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive (80307) and definitive (G0481) drug testing provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid provided on August 6, 2022. 
 
You asked the Plan to pay for a hearing aid. You say that you were denied because you were not an authorized 
person. You also say that you have submitted the representation records. The Plan denied your request. The 
Plan says there is no evidence of pre-authorization for non-contract provider services, and there are two 
contract providers in the area accepting new patients. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when there is a pre-authorization for non-contracted providers, and when services are in-
network.  
 
 We looked at the file, and the Plan's rules. The record shows that the hearing aid was purchased by an out-of-
network provider. Based on this information, we decided that the Plan's rules for coverage of a hearing aid have 
not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid provided on August 6, 
2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

You asked the Plan to pre-approve IRF care. You say that it is medically necessary for you to receive IRF care. The Plan denied your request. The Plan says the Medicare guidelines for IRF admission were not met and the enrollee's need can be met at a lower level of care like a skilled nursing facility (SNF).

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 enrollee is medically stable and does not need physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute nursing needs identified or documented. At the current functional mobility, the enrollee does not need 3 hours a day and 5 days a week of therapies with multidisciplinary approach in an IRF. The enrollee's rehabilitation needs can be safely met in a lower intensity setting.

That the Documentation does not support the medical necessity for admission to an IRF due to lack of medical complexity and lack of nursing needs.
While the enrollee would benefit from physical therapy and occupational therapy the enrollee's rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF.

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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5298) provided on January 13, 2022. 
 
You asked the Plan to pay for a hearing aid (V5298). You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says the hearing benefit is not covered if the services are not registered 
in advance. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when ordered through a Plan provider.  
 
We looked at the file, and the Plan's rules. The Plan rules say that they only cover hearing aids when ordered 
through a Plan provider. The record shows you received your hearing aid from a provider who does not work 
with the Plan. Based on this information, we decided that the Plan's rules for coverage of a hearing aid (V5298) 
have not been met. Therefore, we decided that the Plan does not have to pay for a hearing aid (V5298) 
provided on January 13, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250), and the medical eye examination and evaluation, with initiation or continuation of diagnostic and 
treatment program (92014) provided on May 11, 2022. 
 
You asked the Plan to pay for the vision care. You say that the services were billed correctly. The Plan denied 
your request. The Plan says the enrollees claim would be covered under Original Medicare as it is responsible 
for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before 
rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the fundus photography with interpretation and report 
(92250), and the medical eye examination and evaluation, with initiation or continuation of diagnostic and 
treatment program (92014) provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental extractions and alveoloplasty. 
 
You asked the Plan to pre-approve dental extractions and alveoloplasty. You say that you would like the Plan 
to reconsider their denial. The Plan denied your request. The Plan says the requested extractions and 
alveoloplasty are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers dental 
extractions and alveoloplasty when the services are medically necessary and reasonable.  
 
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 dental extractions and alveoloplasty. 
Our reviewer says that the requested extractions and alveoloplasty are not covered. Our physician reviewer 
found the appeal request is being made for the denial of coverage for full mouth extractions (#'s 3-13, 15, 18, 
20-29 and 31) due to gross caries and non-restorable teeth. The reason for the denial was that the service is not 
covered. Oral surgery treatment may be covered only for the treatment of fractures of the jaw or face, dental 
splints for jaw surgery or the removal of teeth prior to radiation treatment. The documentation does not indicate that the extractions are related to these conditions. The documentation provided does not meet the criteria for 
coverage for the extractions and alveoloplasty as indicated. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of dental extractions and alveoloplasty have not been met. Therefore, we decided 
that the Plan does not have to pre-approve dental extractions and alveoloplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that the ventilator is to be used for the treatment of COPD. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode with Auto-EPAP (AE) that could be delivered by BiPAP 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 a home ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found you have a diagnosis of COPD and were recently hospitalized with pneumonia and COPD exacerbation. There are no pulmonary function tests to assess severity of disease. There is also a diagnosis of ocular myasthenia gravis involving the left eye, but there is no evidence for pulmonary involvement with the myasthenia. An ABG while acutely ill showed no CO2 retention. You do not require nocturnal ventilatory support for COPD because there is no chronic CO2 retention.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
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 there are no services available at the LTACH that you require that are not available and being provided at the health care setting being offered by the health plan.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 61645 billed for services provided on October 19, 2021.

You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says insufficient information has been provided.

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 61645 is percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s).
We find that CPT code 61645 is not supported in the medical record. The medical records provided did not include documentation of the surgical procedure as described by code 61645. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 61645 billed for services provided on October 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a multi-axial rotation unit (L5986). 
 
You asked the Plan to pre-approve a multi-axial rotation unit. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not supported. 
 
The Plan follows Medicare rules. Medicare rules say that an axial rotation unit (L5982, L5984, L5985, L5986) 
is covered for beneficiaries whose functional level is 2 or above. 
 
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 multi-axial rotation unit. Our reviewer 
says that the requirements for coverage have not been met. Our physician reviewer found although records 
from the prosthetist reports the enrollee's functional level is 2, records from the enrollee's treating physician do 
not support this. 
 
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 multi-axial rotation unit have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a multi-axial rotation unit (L5986).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure codes S9500, S9501, and S9502 billed for date of service December 18, 2021, to December 22, 2021.

You asked the Plan to pay for the billed services. You say that the codes are valid. The Plan denied your request. The Plan says the billed code is invalid for Medicare purposes.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate procedure code.

We find that procedure codes S9500, S9501, and S9502 have a Status Indicator of I on the Physician Fee Schedule. This means that the codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes S9500, S9501, and S9502 billed for date of service December 18, 2021, to December 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic guidance for placement of radiation therapy (G6001) also known as image guided radiation therapy (IGRT).

You asked the Plan to pre-approve IGRT. You say that these images are necessary in managing and monitoring the disease throughout the course of Superficial Radiation Therapy. You ask for reconsideration of the decision regarding the approval of the ultrasound imaging, so the enrollee can be a part of the 99% cure rate that SRT has provided thus far. The Plan denied your request. The Plan says the US-IGRT is not medically necessary for superficial radiation therapy.

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 IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found usually, IGRT is used when critical structures are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations and/or IGRT for a technology for which need has not been established by published data or supported by consensus guidelines (many of which recommend against treatment with these devices in general) is not necessary. Billing for daily IGRT and/or simulations would not be furnished in accordance with accepted standards of medical practice.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic guidance for placement of radiation therapy (G6001) also known as image guided radiation therapy (IGRT).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you say you can benefit from a IRF to help build up your strength rather than going into a SNF. The Plan denied your request. The Plan says a IRF admission is not medically necessary, and your needs can be met at an alternate 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 enrollee's medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services Medically necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain fused to predominantly base metal 
tooth #9 (D2751). 
 
You asked the Plan to pre-approve the crown - porcelain fused to predominantly base metal tooth #9 (D2751). 
You say that you need the crown because you are an actor and need it in order for you to make a living. The 
Plan denied your request. The Plan says there is no clinical evidence to support medical necessity. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown - 
porcelain fused to predominantly base metal tooth #9 (D2751) when the services are medically necessary and 
reasonable. Pre-operative periapical radiographs are required documentation for coverage. 
 
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 crown - porcelain fused to 
predominantly base metal tooth #9 (D2751). Our reviewer says that the requested crown on tooth #9 is not 
medically reasonable or necessary. Our physician reviewer found the provided x-ray shows an existing crown 
with apparently intact margins and no other damage seen on tooth #9.  In order to qualify for a replacement crown the existing restoration must be defective in some manner that 
makes the crown unserviceable. Given the supplied information there would be no necessity to replace the 
existing crown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown - porcelain fused to predominantly base metal tooth #9 (D2751) have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to 
predominantly base metal tooth #9 (D2751).
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 there are no services available at the LTACH that the enrollee requires that are not available and being provided at the health care setting being offered by the health plan.

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.