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

 We decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).  You asked the Plan to pre-approve upper and lower partial dentures. You say that you lost your previous dentures and need new ones. The Plan denied your request. The Plan says the requested services would exceed the Plan's frequency limit.  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 upper and lower partial dentures once every 96 months.   We looked at the file and Medicare rules. The Plan provided documentation showing that upper and lower partial dentures were previously covered on February 1, 2018. Based on this information, we decided that the Plan's frequency limit for coverage of upper and lower partial dentures has been exceeded. Therefore, we decided that the Plan does not have to pre-approve the maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve nine (9) additional PT visits.  You asked the Plan to pre-approve nine (9) 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 nine (9) 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. You appear to have plateaued with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. The records do not document any acute or unstable medical conditions or changes in treatment which would necessitate any further skilled therapy visits beyond what have already been approved. No medical notes from your treating physician are provided documenting an order or need for additional skilled therapy services. There is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your 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 nine (9) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve nine (9) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an epidural injection (62321) with monitored anesthesia care (01992).  You asked the Plan to pay for an epidural injection with monitored anesthesia care. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that repeat epidural steroid injections (ESI) when the first injection directly and significantly provided improvement of the condition being treated may be considered medically reasonable and necessary when the medical record documents at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using the same scale for at least three months.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for an epidural injection with monitored anesthesia care. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found there is documentation that the enrollee previously underwent a lumbar epidural steroid injection (ESI), however, there is no documentation that she received any improvement in pain relief and function following this 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 an epidural injection with monitored anesthesia care have not been met. Therefore, we decided that the Plan does not have to pay for an epidural injection (62321) with monitored anesthesia care (01992).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 95180 (3 units) and 95165 (20 units) billed for date of service August 13, 2021.  You asked the Plan to pay for procedure codes 95180 and 95165. You say that the medical records justify payment of these codes. The Plan denied your request. The Plan says these codes are not supported in the medical record.  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 95165 is Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single or multiple antigens (specify number of doses); and the definition of code 95180 is Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum).  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 procedure codes 95180 and 95165. Our reviewer says that the billing of these codes is not supported in the medical records. Our reviewer found that for code 95165, the records do not include documentation to verify that the correct units have been billed.  For code 95180, our reviewer found that the documentation does not include time spent for this procedure, and units cannot be verified or confirmed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 95180 and 95165 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95180 (3 units) and 95165 (20 units) billed for date of service August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies and other services related to anesthesia provided on August 17, 2021.  You asked the Plan to pay for the anesthesia-related items and services. You say that because you perform these services in a doctor's office you must bring all your equipment and should be paid for these items. The Plan denied your request. The Plan says these codes are not payable.  The Plan must follow Medicare rules. Medicare rules say that anesthesia payment is made through the anesthesia fee schedule. It is noted that drugs, supplies, or materials are not separately payable. Therefore, we decided that the Plan does not have to pay for the supplies and other services related to anesthesia provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited (problem focused) oral evaluation (D0140) and re-cement of crown (D2920) provided on October 29, 2021.  You asked the Plan to pay for the limited exam and re-cement of crown. You say that this provider's office is listed as an in-network provider. The Plan denied your request. The Plan says you previously received a limited oral evaluation and a re-cement of a crown for tooth #1 on May 4, 2021. Emergency oral evaluation problem focused exams may only be covered once every 12 months. Recement of crowns and onlays is covered once per tooth per 12 months.  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 can cover one limited (problem focused) exam every 12 months. The Plan can cover one recement of a crown per tooth per 12 months.  Though the Plan offers a dental benefit in excess of Medicare coverage, the services are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you had a previous limited oral exam and re-cement of tooth #1 provided in May 2021, which is less than 12 months before the date in question. The recement of crown was provided for tooth #1 on both dates of service. Therefore, we decided that the Plan does not have to pay for the limited (problem focused) oral evaluation (D0140) and re-cement of crown (D2920) provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided March 4, 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 the documentation does not support the services 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.  We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (G0483) provided March 4, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the Unlisted procedure, nervous system (64999) provided on August 3, 2021.  You asked the Plan to pay for code 64999. You say that the medical records support the billing of code 64999 provided on August 3, 2021. The Plan denied your request. The Plan says that the medical records do not support the billing of code 64999 provided on August 3, 2021.  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 64999 is Unlisted procedure, nervous system.  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 code 64999. Our reviewer says that the medical records support the billing of code 64999 provided on August 3, 2021. Our reviewer found based on review of the operative report and research for an Endoscopic endonasal transphenoidal transclival transellar approach for resection of the clival chordoma, CPT 62161 - 62165 are the options for this procedure.  However, the operative report does not support these procedures, and therefore an unlisted procedure code would be reported.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 64999 have been met. Therefore, we decided that the Plan has to pay for the Unlisted procedure, nervous system (64999) provided on August 3, 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.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the liquid biopsy rendered on March 29, 2021.  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 services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has gastric adencarcinoma diagnosed in March of 2021. A computed tomography (CT) scan demonstrated likely metastatic disease in the liver and spleen. It is documented that the enrollee is a candidate for palliative chemo/immunotherapy. While the enrollee has suspected stage IV cancer, the enrollee was not to be receiving therapeutic chemotherapy. The documentation does not support that the testing was 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the liquid biopsy rendered on March 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the upper extremity prosthesis (L37499)  You asked the Plan to pre-approve the upper extremity prosthesis. You say that you would like reconsideration because the requested prosthesis is medically necessary and will provide the member with much more functionality. The Plan denied your request. The Plan says the requested prosthesis cannot be covered as the incorrect code is used  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 L37499 is upper extremity prosthesis, not otherwise specified.   We find that CPT code L37499 is not supported in the record. Specifically, there are specific codes that must be used to represent the requested prosthesis. In this case, the code submitted for authorization is not appropriate for the requested prosthesis. Based on this information, we decided that Medicare rules for coverage of the upper extremity prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve the upper extremity prosthesis (L37499)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.  You asked the Plan to pre-approve these compression stockings. You say that the requested compression stockings re medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate for your use, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot insert (L3020).  You asked the Plan to pre-approve foot orthotics. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot insert (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with a chiropractor for Trigeminal neuralgia.  You asked the Plan to pre-approve this provider. You say that you have been treated by this provider for spine issues and would now like him to treat your trigeminal neuralgia The Plan denied your request. The Plan says treatment for this type of neuralgia is not covered when rendered by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve treatment with a chiropractor for Trigeminal neuralgia.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 We decided that the Plan has to reduce the cost-sharing charges for DME. We decided that the Plan does not have to reduce the cost-sharing charges for DME to the amount you requested.   You asked the Plan to waive the coinsurance for DME. You say that you were not notified of the charges until much later and feel that you should not be held responsible. The Plan says that the claims were processed correctly and you are being charged the correct amount.  We decided that the Plan has to reduce the cost-sharing charges for DME from $35.60 to $28.48.  The Plan says that you must pay $35.60 for DME. However, you cannot be asked to pay more than 20% coinsurance of the allowed amount for DME. Therefore, we decided that the Plan has to reduce the cost-sharing charges for DME from $35.60 to $28.48.   We also decided that the Plan does not have to reduce the cost-sharing charges for DME to the amount you requested.   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 0% coinsurance for Medicare covered items with a total rental or purchase price of $50 or less and 20% coinsurance for Medicare covered items with a total rental or perchance price of $50.01 or more for DME and related supplies.   You receive DME on January 22, 2020. The total allowed amount is $142.42 and 20% of that is $28.48. Therefore, we decided that the Plan does not have to waive the coinsurance for DME.  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 pre-approve a custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).  You asked the Plan to pre-approve the custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that you have been toothless for a very long time and are now ready for the final replacement crown. You also say that you do not understand why this medical procedure is not covered. The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.  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 a custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.  You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF admission is 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 that the enrollee 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 enrollee's high 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. The enrollee does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.