Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99153) provided March 10, 2021.
You asked the Plan to pay for anesthesia services. You say that the service was medically necessary. The Plan denied your request. The Plan says this code is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99153 is not supported in the medical record. Specifically, the code billed has a Professional Component / Technical Component indicator of 3 per the National Physician Fee Schedule and is not eligible for separate payment at the place of service billed. Based on this information, we decided that Medicare rules for coverage of anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99153) provided March 10, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical (D0230) provided on May 18, 2021.
You asked the Plan to pay for the periapical. You say that you would like reconsideration because these were the first plates made this year. The Plan denied your request. The Plan says you have exceeded the maximum for this benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested periapical exceed the Plan's benefit. Specifically, the record indicates that you received four periapical and two bitewings on June 3, 2020, through June 24, 2020. Therefore, we decided that the Plan does not have to pay for the periapical (D0230) provided on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for chemical cauterization of granulation 
tissue provided from September 15, 2020, to March 10, 2021. 
 
You asked the Plan to waive the copayments for chemical cauterization of granulation tissue. You say that you 
disagree with the charges because you thought that you would only owe a $30 copayment. The Plan denied 
your request. The Plan says the claims were processed correctly and you are being charged the correct amount. 
 
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 $250 
copayment for outpatient surgery, including services provided at hospital facilities and ambulatory surgical 
centers. 

You received chemical cauterization of granulation tissue from September 15, 2020, to March 10, 2021, at an 
outpatient hospital facility, for a total of 22 services. Chemical cauterization of granulation tissue is considered 
an outpatient surgical procedure. Therefore, you are responsible to pay the total copayment amount of 
$1,562.71.  
 
You have been asked to pay the total copayment amount of $1,562.71 for chemical cauterization of granulation 
tissue. Chemical cauterization of granulation tissue falls within the outpatient surgery, including services 
provided at hospital facilities and ambulatory surgical centers benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayments for chemical cauterization of granulation tissue provided from September 15, 2020, to 
March 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation to be performed by an endodontist.
You asked the Plan to pre-approve a consultation to be performed by an endodontist. You say that the services
are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage
criteria has not been met.
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 says covered dental
services must be performed by a participating general dentist.
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of a consultation to be performed by an endodontist have not been met. Therefore, we decided that
the Plan does not have to pre-approve a consultation to be performed by an endodontist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve these services. You say that you have glaucoma and a corneal transplant.
The Plan denied your request. The Plan says the services are available from network providers.
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
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for future physical therapy (PT) visits.
You asked the Plan to waive the copayments for future PT visits. You say that you cannot afford to keep up with these copayments. The Plan denied your request. The Plan says enrollees are responsible for paying copayments for all PT services.
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 PT visits. You have been asked to pay a $40 copayment for future PT visits. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for future physical therapy (PT) visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right reverse total shoulder arthroplasty.
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 services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has primary osteoarthritis
of the right shoulder. She presented with right shoulder pain and lack of function. She has significant overall
grind which makes it nearly unusable for lifting any objects. X-rays are noted to show severe degenerative
arthropathy to the shoulder. However, detailed documentation is not evident regarding an irreparable rotator
cuff. There is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an
effective and/or safe treatment for the noted pathology. 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 request for right reverse total shoulder arthroplasty is 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a right reverse total shoulder arthroplasty.
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 you would like LTACH care covered. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.
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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to oral surgery.
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 services 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 Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. The supplemental benefit does not cover oral surgery services. The
services are not covered by your medical benefit because they are not to prepare the jaw for radiation, but for
care after receiving radiation treatments. Therefore, we decided that the Plan does not have to pre-approve a
referral to oral surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you need constant care that you cannot receive at
home. The Plan denied your request. The Plan says your needs are custodial.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the records show that you do not have skilled
nursing needs. While you need therapy, you do not need it on a daily basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an adjacent tissue transfer provided on June
29, 2021.
You asked the Plan to waive the copayment for an adjacent tissue transfer. You say that you disagree with the
out-of-network charges and feel that you should only owe a $45 copayment. The Plan denied your request. The
Plan says the claims were processed correctly and you are being charged the correct amount.
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 $350
copayment for outpatient surgery, including services provided at ambulatory surgical centers.
The record shows that you received an adjacent tissue transfer at an ambulatory surgical center on June 29,
2021. Therefore, you are responsible to pay the $350 copayment.
You have been asked to pay a $350 copayment for an adjacent tissue transfer. An adjacent tissue transfer falls
within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers benefit category. 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 an adjacent tissue transfer
provided on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for a non-union of fracture was not met.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.
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 stimulator. Our reviewer says that the requested stimulator is not medically reasonable or necessary. Our physician reviewer found the enrollee was being treated for other fracture of shaft of right ulna, initial encounter for closed fracture. He has diabetes which is a risk factor for nonunion and the ability for the bone to heal. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is imaging evidence of some callous formation as noted on 7/26/21 x-rays. 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 request for electrical bone growth stimulator is 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 the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, paravertebral facet joint 
nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code(s): 64635 
and 64636), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the enrollee is in severe pain and that affects their 
quality of life. You state that the enrollee needs the procedure as soon as possible. The Plan denied your 
request. The Plan says the enrollee's records show the enrollee did not have the appropriate level of pain relief 
from an ablation performed this year. 

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 review has determined that the enrollee has not met all of the criteria for coverage in LCD 33930 for 
the RFA. It is not reasonable and medically necessary for the enrollee to have the RFA.  
 
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 destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 
(fluoroscopy or CT); lumbar or sacral, single facet joint (CPT code(s): 64635 and 64636), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breath hydrogen/methane test.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says this test is excluded from coverage when used to search for bacterial overgrowth.
The Plan must follow Medicare rules. The rules say that lactulose breath hydrogen for diagnosing small bowel bacterial overgrowth and measuring small bowel transit time is excluded from coverage. The requested test is being requested to rule out small intestinal bacterial overgrowth (SIBO). Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve a breath hydrogen/methane test.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve a power mobility device. You say that this item is needed so that you can do
your errands and grocery shopping by yourself. You said that you have no friends or family to assist with this.
The Plan denied your request. The Plan says power mobility devices for use outside the home are not covered.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a power mobility device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve the SNF admission. You say that it is felt that SNF care is the best option. 
The Plan denied your request. The Plan says the SNF level of care is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is an 89-year-old man 
with a history of hypertension, who presented to the hospital with fever, weakness, bilateral lung infiltrates, and 
metabolic encephalopathy with underlying dementia. It was thought that the enrollee had a viral illness. On 
10/7/21, the enrollee demonstrated increased functional mobility with transfers, bed mobility, and ambulation 
with close supervision. 
 
No required skilled nursing services are identified. The documentation supports that the enrollee would likely 
benefit from skilled therapy services; however, these services are not needed on a daily basis. 
 
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 admission have not been met. Therefore, we decided that the Plan does 
not have to pre-approve admission to a skilled nursing facility (SNF).
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 skilled nursing facility (SNF) services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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 skilled nursing facility (SNF) services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found your condition does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. The functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a 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 skilled nursing facility (SNF) services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.