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

We decided that the Plan does not have to pre-approve CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says Quantitative Calcium Scoring is not a covered service and will be denied as not medically necessary. The Plan states calcium scoring reported in isolation is considered a screening service. The Plan states when performed in association with CT angiography, there is neither separate nor additional included reimbursement for the calcium scoring.
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, the CT scan, is being 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 pre-approve CT scan, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve supply allowance for therapeutic CGM (CPT code K0553).
You asked the Plan to pre-approve the CGM. You say that you only have two (2) weeks worth of sensors left. You state you like using the freestyle libre because you can immediately get the feedback on how your food choices can affect your glucose levels because often it is not practical to do a finger stab including when you are out of the house. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. Review of the records show that you are treated with insulin injections twice a day, and not multiple (three or more) daily injections as outlined in the Medicare rules. Additionally, the clinical information indicates that you are not adjusting your insulin regimen based on your blood sugar readings. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve supply allowance for therapeutic CGM (CPT code K0553).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy (45385).
You asked the Plan to pre-approve the colonoscopy. You say that the colonoscopy is medically necessary. The Plan denied your request. The Plan says a repeat colonoscopy is only medically necessary after 10 years.
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 colonoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found per the American Academy of Family Practice, patients with small, distal hyperplastic polyps are considered to have a normal colonoscopy result and should have repeat colonoscopy in 10 years. A more frequent colonoscopy is 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 colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy (45385).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac (SI) joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code 27279), for the enrollee.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 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 services. Our physician reviewer found the criteria are not met. There is no documentation of an adequate trial and failure of physical therapy (PT) for back pain. More conservative measures 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 arthrodesis, sacroiliac (SI) joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code 27279), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic evaluation (D0120),
and panoramic x-ray (D0330) provided on April 5, 2021, by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you did not expect to be charged for these
services and would not have had them done if you knew they were not covered. The Plan denied your request.
The Plan says the services are covered, but you used an out-of-network provider who charged more than the
Plan's rate for these services. When you receive care from an out-of-network provider, you may be billed for
any amount that exceeds the Plan's maximum allowed payment for a service.
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's contract lists
periodic oral exams, cleanings, and panoramic x-rays as requiring a $0 copayment. For services obtained outof-
network, the Plan only pays up to a certain amount. If you choose to see an out-of-network dentist, you
might be billed for charges above what the Plan pays, even for services listed with a $0 copayment.
The provider billed the Plan a total of $302.35 for the services provided on April 5, 2021. The Plan's maximum
allowed amount for these services is $113. The Plan has paid the full allowed amount for these services. This is
the amount that an in-network provider would accept as full payment for these services, but out-of-network
providers do not have this agreement with the Plan and are allowed to bill you for the difference between their
billed amount and the Plan's payment. You have been asked to pay $189.35 ($302.35 - $113 = $189.35). 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 pay for the dental cleaning (D1110), periodic evaluation (D0120), and panoramic xray
(D0330) provided on April 5, 2021, by an out-of-network provider.
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 this is medically necessary. The Plan denied your request. The Plan says the services could be provided in another setting, such as an acute rehabilitation facility, skilled nursing facility, nursing facility, outpatient setting or home care.
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 that at this time the enrollee has not required prolonged mechanical ventilation. There is no documentation that the enrollee is capable of being weaned at this time. The documentation does not support that long-term enteral feeding access has been established and is stable. 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 pre-approve arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (CPT code 27130), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that based on this enrollee's medical history with rheumatoid arthritis and failed conservative therapy, it is your recommendation to proceed with right total hip replacement. The Plan denied your request. The Plan says the documentation submitted does not indicate that the enrollee has attempted any conservative treatment, or that conservative treatment is not appropriate for 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 surgery. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (CPT code 27130), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) provided on June 7, 2021.
You asked the Plan to pay for the primary closure of a sinus perforation. You say that you were not aware that the provider has opted out of Medicare. The Plan denied your request. The Plan says primary closure of a sinus perforation is not listed as a covered service.
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 primary closure of a sinus perforation is not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) provided on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (36000) provided to the enrollee on March 6, 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 CPT 36000 is always bundled into payment for other services not specified, and no separate payment is made per Medicare.
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 36000 is "Introduction of needle or intracatheter, vein." 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 the procedure report documents "US Guided IV Access Area prepped and draped in usual sterile fashion. US guidance used to insert 20G needle in L AC without issue. Good venous return, line flushes and draws". Under certain circumstances CPT 36000 can be billed alone. However, documentation does not include enough information to confirm this procedure would
be billed alone. 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 surgical services (36000) provided to the enrollee on March 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for cardiab rehabilitation.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network providers available.
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 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 an out-of-network referral for cardiab rehabilitation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (75726, 75774) provided on January 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are bundled.
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 codes 75726 and 75774 have a bundled relationship with code 37246 and cannot be paid as billed. These codes cannot be paid as separate line items. 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 (75726, 75774) provided on January 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve the services. You say that a new sleep study is required, due to the need for a new CPAP. 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 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 you had a previous sleep study establishing the diagnosis of obstructive sleep apnea, and titration study on May 11, 2021 that established the positive airway pressure (PAP) settings. You have not been compliant with PAP use, according to the record notes. A new sleep study is not needed at this time. 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 a sleep study.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the anterior resin-based composite (D2330) and two posterior resin-based composites (D2391 x2) provided on May 19, 2021.
You asked the Plan to pay more for the resin-based composites. You say that your dentist advised that you would be responsible for $10 copays for your fillings. The Plan denied your request. The Plan says you must pay $100 toward your deductible for the resin-based composite. The Plan also says that you are responsible for a 20% coinsurance of the total cost of the resin-based composites.
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, you are responsible for the $100 deductible plus the 20% coinsurance for each covered restorative service. Therefore, we decided that the Plan does not have to pay more for the anterior resin-based composite (D2330) and two posterior resin-based composites (D2391 x2) provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 19,
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 Medicare denies coverage for all cardiovascular risk assessment panels for patients with
suspected or documented cardiovascular disease.
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the current evidence does not support that genomic testing leads to improved outcomes for patients with
similar history compared to standard testing and treatment. Therefore, this request for cardiac gene 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for laboratory services provided to the enrollee on May 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance 10MG tab, for the enrollee.
You asked the Plan to pre-approve the medication. You say that it is necessary for the enrollee to start Jardiance. The Plan denied your request. The Plan says Jardiance is a self-administered drug and based on this information, the medication does not fall under Part B coverage. The Plan states the enrollee may have a separate commercial pharmacy benefit or Medicare Part D benefit managed by another carrier.
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 Jardiance 10MG tab, for the enrollee.
Benefits for the medication 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: 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 your rehabilitation needs 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for IRF care have not been met because the request is not medically necessary.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.