Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request.

The Plan says the enrollee does not have lymphedema that extends into the chest, trunk, and/or abdomen. The Plan states the enrollee has not met the coverage criteria for E0650 or E0651, and the enrollee has not had a failed response to treatment with E0650 or E0651. The Plan states the provider did not submit documentation of detailed measurements of the progress or failure of the enrollee's lymphedema to conservative treatments.

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 DME. Our physician reviewer found the record does not show evidence of the patient having lymphedema that extends into the chest, trunk, and/or abdomen. Also, the record does not show that the patient had a failed response to treatment with E0650 or E0651 (device that does not extend to trunk). Therefore, the criteria for the E0667 and E0652 are not met based on the documentation provided. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT code E0652), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient hospital admission and services.

You asked the Plan to pre-approve acute inpatient hospital care. You say that this hospital admission is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an acute inpatient level of care are not met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case.

Our physician reviewer found the enrollee presented to the hospital with dizziness, vertigo, leg pain and related falls at home. Workup revealed that there was no evidence that the enrollee's symptoms were not chronic and ruled out an acute condition. Management of gait instability could be addressed at an observation level of care. The review has determined that the record does not show that the admitting physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute inpatient hospital admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following elective surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that this request is medically necessary. The Plan denied your request. The Plan says inpatient care is not medically reasonable and necessary following the elective surgery.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights.
In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is an 80-year-old female with a history of asthma, hypertension, hypersensitivity lung disease, Osteoarthrosis, Lumbar epidural steroid injections, bilateral knee replacements, and breast cancer. The enrollee is undergoing a planned total shoulder arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under code 23472 is not listed on the Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The review has determined that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care following elective surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one additional pair of eyeglasses (CPT code V2199).
You asked the Plan to pre-approve the additional pair of eyeglasses. You say that your vision has decreased
drastically due to your diabetes. The Plan denied your request. The Plan says additional pairs of eyeglasses or
contacts are not covered by Medicare.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case.
We looked at the file and the Plan's rules. Based on your benefit plan, your request for additional routine
eyewear (eyeglasses) is not approved. You are requesting one additional pair of eyeglasses. Your benefit only
allows one pair of eyeglasses. You have exceeded your benefit limit. Therefore, we decided that the Plan does
not have to pre-approve one additional pair of eyeglasses (CPT code V2199).
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional pouches for a PureWick Catheter System.

You asked the Plan to pre-approve these services. You say that the enrollee needs double the quantity they are receiving. The Plan denied your request. The Plan says the services are not covered.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve additional pouches for a PureWick Catheter System.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the oral evaluation and complete series x-ray. We decided that the Plan does not have to pay for the periapical x-ray, treatment of dental pain, photographic image, crowns, panoramic x-ray, and filling.

You asked the Plan to pay for the dental services. You say that your dentist retired just before the coronavirus started. You say that you did not seek dental care until you were in pain. You say that the provider in this case is listed on the Plan's website as in network. You also say that these services should be covered. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made to providers that have opted out of Medicare.

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.

We decided that the Plan has to pay for the oral evaluation and complete series x-ray.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the oral evaluation and complete series x-ray have been met. The record shows that the enrollee has preventive dental coverage for services. Additionally, the record shows that the provider in this case is in network. Therefore, we decided that the Plan has to pay for the oral evaluation and complete series x-ray.
We also decided that the Plan does not have to pay for the periapical x-ray, treatment of dental pain, photographic image, crowns, panoramic x-ray, and filling.

Though the Plan offers a dental benefit in excess of Medicare coverage, the periapical x-ray, treatment of dental pain, photographic image, crowns, and filling are not among those covered under this benefit. Additionally, the frequency limit of 1 full mouth or panorax x-ray will be reached when the Plan pays for the complete series x-ray provided on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the periapical x-ray, treatment of dental pain, photographic image, crowns, filling and panoramic x-ray.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and electrocardiogram provided on April 13, 2021.
You asked the Plan to waive the copayment for the office visit (99214) and electrocardiogram (93000). You say that you met your deductible so you should not have any copayments. The Plan denied your request. The Plan says you were charged the 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). You have been asked to pay a $35 copayment for the office visit and a $17.51 copayment for the diagnostic procedure, with a $750 deductible. The allowable amount for the electrocardiogram is $17.51 which is less than your copayment. 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 office visit and electrocardiogram provided on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that necessary care cannot be accomplished at a lower
level. The Plan denied your request. The Plan says under Medicare, 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 complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a replacement continuous positive airway pressure device.

You asked the Plan to pre-approve a replacement continuous positive airway pressure (cpap) device (E0601). You say that your CPAP device is under recall. The Plan denied your request. The Plan says that your current CPAP is still under reasonable useful lifetime.

The Plan must follow Medicare rules. The rules say the Plan is responsible for maintaining continuity of care for its enrollee by ensuring uninterrupted access to the medically necessary covered DME item.

The enrollee's CPAP is under recall for a potential health risk. Therefore, we decided that the Plan has to pre-approve a replacement continuous positive airway pressure device.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency diagnostic exam (D0140) provided on May 10, 2021.
You asked the Plan to pay for the dental service. You say that you developed a large abscess above an infected tooth. You say that you were put on penicillin, but the abscess came back. You say that you had to have another emergency exam as a result. You also say that you should be liable for this service. The Plan denied your request. The Plan says 1 emergency diagnostic exam is covered per year. The Plan also says that the frequency limit has been exceeded.
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 looked at 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 frequency limit has been exceeded. The record shows that the Plan paid for an emergency diagnostic exam that you received on March 9, 2021.
Therefore, we decided that the Plan does not have to pay for the emergency diagnostic exam (D0140) provided on May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 27, 2021.

You asked the Plan to waive the copayment for the ambulance services. You say that this copayment is a hardship. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for ambulance services. 

The enrollee has been asked to pay a $200 copayment for the ambulance services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), cleaning (D1110),
bitewing x-rays (D0274) and stainless-steel crown (D2931) provided on January 26, 2021.
You asked the Plan to pay for the dental services. You say that these services were necessary, and you have
previously received payment for services received from this provider. The Plan denied your request. The Plan
says this provider does not participate in Original Medicare. You must see a licensed provider who participates
in the Medicare program in order to receive payment or reimbursement for covered dental care.
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. To use your dental benefits,
you may see any licensed dental provider who accepts Medicare patients in the United States and has not
opted-out of Original Medicare. If you use a provider that has opted-out of Medicare, you will not receive
reimbursement.
Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from a
provider who does not participate in Original Medicare are not covered under this benefit. The record shows
that this provider has chosen to opt-out of participation with the Medicare program. Therefore, we decided that
the Plan does not have to pay for the periodic oral evaluation (D0120), cleaning (D1110), bitewing x-rays
(D0274) and stainless-steel crown (D2931) provided on January 26, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical surgery services coded as 32653 and 36625
provided on April 16, 2021.

You asked the Plan to pay for the medical surgery services. You say that you would like these claims
reprocessed based on the requested documentation. The Plan denied your request. The Plan says the medical
records submitted do not corroborate the codes as billed.

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 32653 is thoracoscopy, surgical; with removal of
intrapleural foreign body or fibrin deposit. The CPT Code Manual definition of code 36625 is arterial
catheterization or cannulation for sampling, monitoring, or transfusion (separate procedure); cutdown.

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 medical surgery services. Our reviewer says that the
documentation does not support the codes billed in this case. Our reviewer found the enrollee is an 80-year-old
woman with a post-traumatic right hemothorax. On 4/16/21, right video thoracoscopy was performed with
evacuation of retained hemothorax. A left femoral arterial line was placed. An attempted left radial artery
cutdown was unsuccessful and was abandoned. Through an initial video thoracoscopic port, the hemithorax
was examined. There was no cortical peel. A large amount of liquified blood was aspirated free. A second port
was placed to assist in complete evacuation of additional liquified blood. At the end of the procedure, Exparel
was injected. In this case, the medical records do not support the billed codes. Regarding code 32653, the
documentation does not support the removal of intrapleural foreign body or fibrin deposit. Regarding code
36625, an attempted left radial artery cutdown was abandoned when there was unsuccessful return of blood
flow.

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 medical surgery services have not been met. Therefore, we decided that the
Plan does not have to pay for the medical surgery services coded as 32653 and 36625 provided on April 16,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA ablations (CPT code(s): 64635-RT and 64636-RT), for the enrollee.

You asked the Plan to pre-approve the services. You say that you would like the denied services to be approved. The Plan denied your request. The Plan says the documentation sent to the Plan showed the enrollee had this procedure two (2) times within the year and the guidelines allow only two in a year.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Your request does not meet the criteria for medical necessity as outlined by Medicare rules. The enrollee has already exhausted their two (2) sessions per spinal region within twelve (12) rolling months. Therefore, we decided that the Plan does not have to pre-approve RFA ablations (CPT code(s): 64635-RT and 64636-RT), for the enrollee.