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

We decided that the Plan does not have to pre-approve echo-guided radiotherapy (G6001).
You asked the Plan to pre-approve the echo-guided radiotherapy.. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 echo-guided radiotherapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found imaging-guided radiotherapy is used when critical structures are abutting or in close proximity to the target that is being treated to high doses. This situation does not apply to this patient as the target lesion can be seen on the skin to assist in daily set up. 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 echo-guided radiotherapy. have not been met. Therefore, we decided that the Plan does not have to pre-approve echo-guided radiotherapy (G6001).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of biomechanical device (22854) and a corpectomy (63090, 63091) provided on February 18, 2021.
You asked the Plan to pay for the insertion of biomechanical device and a corpectomy. You say that this was medically necessary. The Plan denied your request. The Plan says these codes are not documented.
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 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 insertion of biomechanical device and a corpectomy. Our reviewer says that these codes are not supported. Our reviewer found codes 63090 and 63091 are not supported because the operative report does not document removal of damaged vertebrae and intervertebral discs that are compressing the spinal cord and spinal nerves. While code 22854 is documented, this is an add-on code billed
without a payable primary procedure. 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 insertion of biomechanical device and a corpectomy have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of biomechanical device (22854) and a corpectomy (63090, 63091) provided on February 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99199) provided on February 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services are medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to approve payment.
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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The plan has network providers available. No medical records were provided to show that these services were of an emergent or urgent nature.
Therefore, we decided that the Plan does not have to pay for physician services (99199) provided on February 22, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on April 23, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee. The Plan denied your request. The Plan says that rules for psychotherapy services have not been met because there is no documentation of consultation with the attending or primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the only exception to the consultation requirement for clinical social workers is in cases where the patient's primary care or attending physician refers the patient to the clinical social worker. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. The medical records document that the enrollee was referred to the clinical social worker by the enrollee's primary care physician. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older (CPT code 99397).
You asked the Plan to pre-approve the service. You say that you are requesting to have your annual gynecologic exam early with the provider due to travel conflict. The Plan denied your request. The Plan says you do not have a high risk for developing gynecological cancer.
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 service have not been met. Review of the file shows that you do not meet the criteria of having a gynecologic exam before the 24 months listed in your EOC. The health plan contract says covered services include: Pap tests and pelvic exams are covered once every twenty-four (24) months. If you are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past three (3) years: one Pap test every twelve (12) months. Therefore, we decided that the Plan does not have to pre-approve the periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older (CPT code 99397).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for microsurgical technique code 69990 provided on February 23, 2021.
You asked the Plan to pay for 69990. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 69990 has a procedure-to-procedure edit modifier of 0 with code 63030 which means that this code pairing is not allowed.
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 code 69990 has a bundled relationship with code 63030 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.
Therefore, we decided that the Plan does not have to pay for microsurgical technique code 69990 provided on February 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided the Plan does not have to pre-approve a percutaneous electrical nerve stimulation (PENS) device.

You asked the Plan to pre-approve a percutaneous electrical nerve stimulation (PENS) device. You say that a percutaneous electrical nerve stimulation (PENS) device is medically necessary. The Plan denied your request. The Plan says the required Medicare coverage criteria are not met.

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 a percutaneous electrical nerve stimulation (PENS) device. Our reviewer says that this technique is specifically excluded Medicare rules. Therefore, the request is deemed 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 a percutaneous electrical nerve stimulation (PENS) device have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous electrical nerve stimulation (PENS) device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81406, 81407, 81405, 81408) provided January 22, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented Cardiovascular disease.
We looked at the file and Medicare rules. The service at issue is cardiovascular risk assessment testing. This is not a covered service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81406, 81407, 81405, 81408) provided January 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D testing rendered on December 30, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is 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 test at issue in this appeal, a Vitamin D screening, was 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 pay for the Vitamin D testing rendered on December 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital admission and services provided from March 24, 2021, to March 28, 2021.

You asked the Plan to waive the copayment for the inpatient care. You say that you were not admitted to the intensive care unit (ICU) and should not have to pay this bill. The Plan denied your request. The Plan says you were in the hospital as an inpatient for four days. Each of the first five days of inpatient care requires a $250 copayment. This copayment was applied 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 $250 copayment for each of the first five days of Medicare-covered hospital care. 

You have been asked to pay a $1,000 copayment for four days of inpatient care ($250 x 4 = $1,000). It appears that the reason you disagree with this copayment is that you were only in the ICU for a short period of time. Please note that this copayment is not exclusively for the ICU care; it covers all of the eligible inpatient services you received while you were admitted to the hospital from March 24, 2021, to March 28, 2021, and was listed as a lump sum applied to one service on your Explanation of Benefits for simplicity. 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 inpatient hospital admission and services provided from March 24, 2021, to March 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 additional months of the rental of a home ventilator (E0466).
You asked the Plan to pre-approve a home ventilator. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for respiratory assist devices have not been met.
The Plan must follow Medicare rules. Medicare rules say that enrollees covered for the first three months of a respiratory assist device must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. We looked at the file and Medicare rules. In this case, the Plan has approved the rental of a home ventilator for an initial 3 months. During this initial period, the enrollee and physician are to produce a compliance report to document usage of the requested device. The case record does not at present provide documentation of compliance with use of the requested device. Based on this information, we decided that Medicare rules for
coverage of a home ventilator for 9 additional months have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional months of the rental of a home ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from April 28, 2021, to May 1, 2021.

You asked the Plan to pay for the self-administered drugs. You say that you were in the hospital and feel it should be covered in full. The Plan denied your request. The Plan says self-administered drugs are not covered in the outpatient setting under Medicare 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 pay for the self-administered drugs provided from April 28, 2021, to May 1, 2021.

Benefits for the self-administered drugs 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).

You asked the Plan to pre-approve the interspinous spacer placement. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is experimental and is not covered.

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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer device is considered investigational at this time. More research is needed to support safety and efficacy of this procedure. 

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 interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) and osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant (D4261) provided May 24, 2021.
You asked the Plan to pay for the comprehensive periodontal exam and osseus surgery. You say that you talked to the Plan prior to the services being rendered and were under the impression they would be covered with 50% coinsurance. The Plan denied your request. The Plan says these services are not covered under your benefits. The Plan also says they reviewed the call log to confirm that incorrect information about benefits was not provided.
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. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation - new or established patient (D0180) and osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant (D4261) provided May 24, 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 this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.

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 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. The enrollee
was admitted for metabolic encephalopathy, sepsis, pneumonia and seizures. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on March 26, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee. The Plan denied your request. The Plan says that rules for psychotherapy services have not been met because there is no documentation of consultation with the attending or primary care physician.

The Plan must follow Medicare rules. Medicare rules say that the only exception to the consultation requirement for clinical social workers is in cases where the patient's primary care or attending physician refers the patient to the clinical social worker. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have been met. The medical records document that the enrollee was referred to the clinical social worker by the enrollee's primary care physician. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on March 26, 2021.

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.