Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the lower right and upper right quadrants.
You asked the Plan to pre-approve the scalings and planings. You say that you would like to appeal these services. The Plan denied your request. The Plan says this service is allowed one time every 36 months. The Plan also says that you received this service less than 36 months ago on the upper right and lower right quadrants.
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, periodontal scaling and root planing (D4341) is limited to one of either code D4341 or D4342 per 36 months per quadrant.
The record shows that you received periodontal scalings and root planings (D4341) of the lower right and upper right quadrants on January 17, 2019 and your periodontal scaling and root planing (D4341) benefit for the lower right and upper right quadrants has been exhausted through January 17, 2022. Therefore, we decided that the Plan does not have to pre-approve periodontal scalings and root planings (D4341) of the lower right and upper right quadrants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental implants.
You asked the Plan to pre-approve the dental implants. You say that your primary care physician as well as the
oral surgeon agree this procedure is medically necessary. You say that the services should be covered. The Plan
denied your request. The Plan says dental implants 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. Therefore, we decided that the Plan does not have to pre-approve the
dental implants.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and associated
accessory (E0667).
You asked the Plan to pre-approve a pneumatic compression device and associated accessory. You say that the
requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for
coverage for pneumatic compression devices have not been met.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. The item coded E0667 is not separately payable when the base item is not covered. Therefore, we
decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and associated
accessory (E0667).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve BRCA1/BRCA2 testing.
You asked the Plan to pre-approve BRCA1/BRCA2 testing. You say that the requested BRCA1/BRCA2 testing is medically necessary. The Plan denied your request. The Plan says that the requested BRCA1/BRCA2 testing is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 BRCA1/BRCA2 testing. Our reviewer says that the requested BRCA1/BRCA2 testing is medically necessary. Our physician reviewer found the enrollee meets criteria for genetic testing for a BRCA1 and BRCA2 coverage based on both CMS and NCCN guidelines. She has both a personal history of breast cancer and at least 2 close relatives (2 sisters if not more) diagnosed with breast cancer. A positive result could impact screening recommendations, option of prophylactic mastectomies, and future treatment options. The service is reasonable and 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 BRCA1/BRCA2 testing have been met. Therefore, we decided that the Plan has to pre-approve BRCA1/BRCA2 testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second and third interlaminar epidural injection (ESI).
You asked the Plan to pre-approve more than one interlaminar ESI. You say that the records provided support the need for the injection services which remain in dispute. The Plan denied your request. The Plan says the requested procedure is not supported without a treatment plan showing that the enrollee will not exceed the limitations.
The Plan follows Medicare rules. Medicare rules say that lumbar epidural injections are covered for certain indications. 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 second and third interlaminar ESI. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was diagnosed with lumbar spinal stenosis with neurogenic claudication. Based on submitted documentation, this enrollee reports lumbar back pain and bilateral lower extremity weakness. The pain is rated 3/10. She denies tingling, weakness, or changes in bowel or bladder function. She is ambulating and uses a wheelchair. No more than two transforaminal injections may be performed at a single setting. One caudal or lumbar interlaminar injection is allowed per session and not in conjunction with a lumbar transforaminal injection. 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 second and third interlaminar ESI have not been met. Therefore, we decided that the Plan does not have to pre-approve a second and third interlaminar epidural injection (ESI).
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 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 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: 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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 following discharge, you went to a subacute facility and are now in long term care. The records do not demonstrate that you require acute care 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are no
longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued inpatient services from November 8, 2021, were requested. 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 continued services. Our physician reviewer found that active services were
not taking place. The services were not reasonably expected to improve your condition or for the purpose of
diagnosis beyond the date in question.
You do not appear to require inpatient mental health treatment beyond the date in question as you were not a
danger to yourself or others and did not have any delusions, auditory or visual hallucinations. You were being
cooperative with treatment. Therefore, the requested services are 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued inpatient psychiatric services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 2, 2021.
You asked the Plan to pay for this service. . You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for compounded drugs (J3490, J7999) and administration (96372) provided on December 29, 2020.
You asked the Plan to pay for compounded drugs and administration. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. We looked at the file and Medicare rules. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using only the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of compounded drugs and administration have not been met. Therefore, we decided that the Plan does not have to pay for compounded drugs (J3490, J7999) and administration (96372) provided on December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the initial hospital care services coded 99222 provided on December 17, 2020.
You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that an edit exists between codes 36556 and 99222.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan states there is an edit that exists between codes 36556 and 99222 and that this edit has a modifier indicator of 1. However, a search of codes 36556 and 99222 show there is no edit between these two codes. Therefore, the Plan has not accurately showed why this code is not payable. The Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the initial hospital care services coded 99222 provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous electrical stimulator.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation.
We looked at the file, and Medicare rules. In this case, there are insufficient medical records to show that the requested services are necessary to treat your condition. The file shows that the Plan made multiple attempts to obtain additional information, but none were provided. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous electrical stimulator.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine.
You asked the Plan to pre-approve an MRI of the thoracic spine. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 an MRI of the thoracic spine. Our reviewer says that the services are medically necessary. Our physician reviewer found while the MRI of April 5, 2021 showed no evidence of a tumor, the fact that residual tumor was questioned in the past it is reasonable to perform a surveillance MRI at this point since the tumor could be slow growing in nature and residual tumor has been questioned within the past year. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an MRI of the thoracic spine have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from April 12, 2021, to April 13, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the hospital just gave you oxygen and didn't do anything else. You state that under your benefits, hospitalization should be covered 100% The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for days 1-3 for inpatient hospital care. Records show that you were an inpatient for one day. You have been asked to pay a $250 copayment for your one-day stay. 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 inpatient hospital services you received from April 12, 2021, to April 13, 2021.
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 SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee required contact guard to stand-by assistance with functional mobility including walking to 250 feet times three. The documentation does not support that the enrollee requires skilled nursing or skilled therapy services on a daily basis. 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the thyroid testing provided on May 3, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered screening test.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the thyroid testing provided on May 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for myocardial perfusion imaging provided on June 15, 2021.
You asked the Plan to waive the copayment for myocardial perfusion imaging. You say that your doctor ordered a different test and you were told you would owe a lesser amount. 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 nuclear medicine provided at an outpatient hospital facility. The record shows that you received myocardial perfusion imaging at an outpatient hospital facility on June 15, 2021. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for myocardial perfusion imaging. Myocardial perfusion imaging falls within the outpatient diagnostic tests and therapeutic services and supplies 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 myocardial perfusion imaging provided on June 15, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electromyogram services you received at an outpatient hospital facility on June 9, 2021.
You asked the Plan to waive the copayment for the electromyogram services. You say that you called your neurologist because you needed this study. They advised you that you would need to have the test and then come back again for the results. You said this would have cost as much as going to the hospital for this test. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $175 copayment for diagnostic procedures in an outpatient facility.
You have been asked to pay a $175 copayment for the electromyogram services. The electromyogram services fall within the diagnostic procedures in an outpatient facility 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 the electromyogram services you received at an outpatient hospital facility on June 9, 2021.