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

We decided that the Plan does not have to pay for the lab services provided on February 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says screening tests are 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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira for the enrollee.  You asked the Plan to pre-approve Humira. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. 
Therefore, we decided that the Plan does not have to pre-approve Humira for the enrollee.      
Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high gold content crown (D2790) for tooth # 15.  You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan denied your request. The Plan says tooth # 15 does not have significant breakdown to warrant a crown.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental service 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 the dental service. Our reviewer says that a crown for tooth # 15 is not medically necessary. Our physician reviewer found he provided x-rays and photos show four intact cusps, and four surfaces that are likely involved.  Although a crown could be placed, the requirement of the Plan that two cusps be involved to consider a crown has not been met as all cusps are intact.  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 dental service have not been met. Specifically, the file shows that all 4 cusps are intact. Therefore, we decided that the Plan does not have to pre-approve a high gold content crown (D2790) for tooth # 15.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Jenny Craig program fees and frozen meals purchased from September 28, 2020, to January 1, 2021.  You asked the Plan to pay for weight loss program fees and meals. 
You say that these services should be covered because you have coverage for the Jenny Craig program under your weight management benefit. The Plan denied your request. The Plan says the purchases made in 2020 cannot be paid because these claims were received after the March 31, 2021 deadline for 2020 purchases. In addition, the frozen meals are not covered under the weight management benefit.  The rules say that Medicare does not cover gym or weight loss benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
The Plan offers a weight management benefit, which covers program fees for weight loss programs such as WeightWatchers, Jenny Craig, or a hospital-based weight loss program. This benefit does not cover costs for pre-packaged meals/foods, books, videos, scales, or other items or supplies. The Plan will reimburse members up to a maximum of $150 per calendar year towards program fees for weight loss programs. 
Reimbursement requests must be received by the Plan by no later than March 31st of the following year.   
The Plan's rules for coverage of gym benefits have not been met for the program fees purchased in 2020, as this request was not received by the Plan until May of 2021. Reimbursement requests must be received by the Plan no later than March 31st of the following year. This means that the purchases made in 2020 needed to be submitted to the Plan by March 31, 2021. Therefore, payment cannot be provided for the 2020 claims. In addition, you purchased frozen/pre-packaged meals through this program on January 1, 2021. This benefit does not cover costs for pre-packaged meals/foods. Therefore, we decided that the Plan does not have to pay for Jenny Craig program fees and frozen meals purchased from September 28, 2020, to January 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure 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 unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  
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 this procedure is experimental. More research 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with an otolaryngologist on March 15, 2021.  You asked the Plan to waive the copayment for the otolaryngology visit. You say that there is no copayment for hearing exams, so there should be no copayment for this visit. 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 $40 copayment for visits with a specialist.   You have been asked to pay a $40 copayment for the otolaryngology visit. We looked at the medical records from this visit to see what services you received.  
The records show that you did not just have a hearing test.  Rather, you had a full office visit that assessed you for tinnitus and you had impacted ear wax removed.  These services are beyond the scope of a hearing test.  That is why the specialist visit copayment applies. 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 visit you had with an otolaryngologist on March 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 23, 2021, to August 21, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive skilled services.  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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  
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 care have not been met. Specifically, the file shows that the enrollee did not receive daily skilled services on the dates of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from July 23, 2021, to August 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Darzalex Faspro.  You asked the Plan to pre-approve Darzalex Faspro. You say that this request is medically reasonable and necessary. The Plan denied your request. The Plan says the requested drug is experimental/investigational for the enrollee's condition.  
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Darzalex Faspro. 
Our reviewer says that the requested drug is not medically reasonable and necessary for the enrollee's condition. Our physician reviewer found the enrollee has been diagnosed with multiple myeloma. In addition, they have been diagnosed with dementia anemia. The use of Darzalex Faspro is not FDA-approved for the enrollee's diagnosis as a single agent.  
Furthermore, the use of the requested drug is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Darzalex Faspro have not been met. Therefore, we decided that the Plan does not have to pre-approve Darzalex Faspro.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 27, 2020, to October 29, 2020.  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 there was a change from DRG 872 to DRG 690.  
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    
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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found sepsis without septic shock was listed as a diagnosis during this visit. Based on the provided documenation, the Sepsis-3 score was 1 which is low risk of sepsis. Therefore, the DRG 872 would not be appropriate, however, the suggested DRG 690 would be appropriate and correct for this hospitalization.    We looked at this physician's review, the file, and Medicare rules. 
Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from October 27, 2020, to October 29, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation (A0422) and oximetry services (94760) provided on March 12, 2021.  You asked the Plan to pay for ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation and oximetry services (94760). The Plan denied your request. The Plan says these are considered part of the general ambulance service and payment for them is included in the payment rate for the transport.  The Plan must follow Medicare rules. Medicare rules say that payment for items and services, such as oxygen, is included in the fee schedule payment.   We looked at the file and Medicare rules. Medicare says that payment for items and services, such as oxygen, is included in the fee schedule payment. Therefore, we decided that the Plan does not have to pay for ambulance (als or bls) oxygen and oxygen supplies, life sustaining situation (A0422) and oximetry services (94760) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a tooth extraction (D7210 and D7140), and an alveoloplasty in conjunction with extractions (D7310) provided by an out-of-network provider on May 26, 2021.  You asked the Plan to pay for a tooth extraction and an alveoloplasty in conjunction with extraction. You say that you do not agree with these charges. The Plan denied your request. The Plan says these charges have been correctly applied.  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, D7310 is not among those covered under this benefit. D7210 and D7140 are covered at a 50% coinsurance. Therefore, we decided that the Plan does not have to pay for a tooth extraction (D7210 and D7140), and an alveoloplasty in conjunction with extractions (D7310) provided by an out-of-network on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing including antibiotic resistant markers (87799, 87798, 87482, and 87150) provided on August 5, 2021.  You asked the Plan to pay for the urine PCR panel testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the standard of care for the evaluation of a potential urinary infection is urinalysis with urine culture and sensitivity.  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 urine PCR panel testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found the standard of care for the evaluation of a potential urinary infection is urinalysis with urine culture and sensitivity.  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 urine PCR panel testing have not been met. Therefore, we decided that the Plan does not have to pay for urine polymerase chain reaction (PCR) panel testing including antibiotic resistant markers (87799, 87798, 87482, and 87150) provided on August 5, 2021.
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 SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not require complex daily nursing care that must be provided in a skilled nursing facility.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services, 13 hours, per week (G0156) and direct skilled nursing services, one hour visit, per week (G0299).

You asked the Plan to pre-approve the home health services. You say that you would like to appeal the denial of services because you need the services as you feel it is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for the requested services.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 the home health services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the limited documentation provided, the health Plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy). As such, the requested home health, skilled nursing services and associated home health aide services are not medically necessary, reasonable or coverable.

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 health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide services, 13 hours, per week (G0156) and direct skilled nursing services, one hour visit, per week (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal bone growth (osteogenesis) stimulator (E0748).

You asked the Plan to pre-approve the spinal osteogenesis stimulator. You say that the medical records provided support the necessity of the services. The Plan denied your request. The Plan says the records do not support that the enrollee meets the Medicare criteria for coverage.

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 spinal osteogenesis stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria not met. Not enough time (9 months) has passed since surgery. Also, only 2 levels of the cervical spine were fused. 

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 spinal osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal bone growth (osteogenesis) stimulator (E0748).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services (procedure code 99253) provided to the enrollee on February 5, 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 this is not a payable 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, the CPT Code Manual definition of code 99253 is "Inpatient consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 55 minutes are spent at the bedside and on the patient's hospital floor or unit."

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found Medicare no longer covers consultation codes. There is a more appropriate code to report for these services.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for inpatient services (procedure code 99253) provided to the enrollee on February 5, 2021.