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

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says there is already assistive equipment for use inside the home.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home.
According to the available records, the power scooter is being requested for use outside the home. There is no documentation that your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. There is no documentation that you can safely operate the power scooter. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from May 6, 2021 to May 12, 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 submitted records do not support the billing of DRG 682, primary diagnosis code N17.0, and secondary diagnosis code G93.41.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with DRG 682 (renal failure with MCC) and primary diagnosis N17.0 (acute kidney failure with tubular necrosis) and secondary diagnosis G93.41 (metabolic encephalopathy). 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 submitted records do not support the billing of DRG 682, primary diagnosis code N17.0, and secondary diagnosis code G93.41. Our physician reviewer found the records support an admission for pneumonitis due to inhalation of food and vomit but is inconsistent regarding diagnoses N17.0 and G93.41. On presentation, he was alert and oriented to person, place, and time. He was admitted for dehydration and elevated sodium. While the presentation warranted consideration of acute kidney injury and encephalopathy as possible diagnoses, there was no evidence of increase in baseline serum creatine documented by physician by 3.0 times baseline, initiation of renal replacement therapy or dialysis, urinary sodium greater than 40 mEq/L, or UA with non-hyaline casts or renal biopsy confirmation. There was no evidence of neurological symptoms documented by the provider to be beyond the enrollee's baseline and potential cause and treatment to address diagnosis of encephalopathy. The diagnoses are therefore not supported.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from May 6, 2021 to May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bedside commode (E0163).
You asked the Plan to pre-approve the commode. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not show that the enrollee is confined to one room, confined to one level of a home that does not have a toilet on that level, or confined to a home that does not have a toilet.
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 commode. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show that the enrollee was confined to one room, confined to one level of a home that does not have toilet on that level or confined to a home that does not have a toilet. The review has determined that the records do not show evidence of any of the three criteria listed in the LCD.
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 commode have not been met. Therefore, we decided that the Plan does not have to pre-approve a bedside commode (E0163).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392) provided on August 11, 2021.
You asked the Plan to pay for the resin-based composite. You say that the information provided made it appear as if additional dental work was at least partially covered. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan. The Plan also says that there were no calls located prior to receiving this service to confirm your dental benefits, and you were not enrolled in the Supplemental Dental Rider.
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 resin-based composite (D2392) provided on August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 19, 2021, to July 18, 2021.
You asked the Plan to pay for the services. You say that this office is authorized to pursue a claim for Medicare coverage for services provided to the enrollee. The Plan denied your request. The Plan says the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long term care facility, or in the home with home health care services.
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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, there is no documentation that the enrollee required skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse or qualified therapist were not required to safely and effectively provide medically necessary and reasonable treatment from 06/19/2021, to 07/18/2021. Daily skilled services were not required. The enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the nursing facility appear custodial in this case from 06/19/2021, to 07/18/2021. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from June 19, 2021, to July 18, 2021
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on July 22, 2021.
You asked the Plan to waive the copayment for emergency care. You say that no one will provide an explanation for the charges. You state that you never saw a physician. 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 $90 copayment for emergency care. The medical records show that you received emergency care on July 22, 2021. Therefore, you are responsible to pay the $90 copayment. You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on July
22, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the left knee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has advanced left knee osteoarthritis. She is planned for a total knee arthroplasty with robotic assistance. The peer-reviewed literature supports the necessity of pre-operative CT scans of the knee as critical planning prior to robotic-assisted total knee arthroplasty. The CT scan 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the left knee.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient mental health care provided from January 5, 2021, to May 4, 2021.
You asked the Plan to waive the copayments for outpatient mental health care. You say that the claims originally processed with no cost-sharing charges. 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 $40 copayment for outpatient mental health care. You received outpatient mental health care form January 5, 2021, to May 4, 2021, for a total of 5 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40
(copayment) x 5 (outpatient mental health visits) = $200. You have been asked to pay the total copayment amount of $200 for outpatient mental health care. Outpatient mental health care falls within the outpatient mental health care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient mental health care provided from January 5, 2021, to May 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for electroconvulsive therapy (ECT) treatment you received at an outpatient hospital facility on January 10, 2020.
You asked the Plan to waive the copayment for the ECT treatment. You say that you are upset that you received this bill so long after the services were rendered. 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 $360 copayment per visit for outpatient hospital services. You have been asked to pay a $360 copayment per visit for the ECT treatment. This copayment applies regardless of when you are billed. 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 electroconvulsive therapy (ECT) treatment you received at an outpatient hospital facility on January 10, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve removal of tooth roots (D7250) for tooth # 5.  You asked the Plan to pre-approve the dental service. You say that the service is necessary. The Plan denied your request. The Plan says removal of tooth roots is covered once per tooth, per lifetime. The Plan also says that the frequency limit has been reached.  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 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 file shows that the frequency limit has been reached. The record shows that the Plan paid for a removal of tooth roots for tooth # 5 that you received on October 19, 2021. Therefore, we decided that the Plan does not have to pre-approve removal of tooth roots (D7250) for tooth # 5.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a general health panel (80050) and other laboratory services (81000, 84153) provided on September 29, 2020.
You asked the Plan to pay for a general health panel and other laboratory services. You say that these services should be covered. The Plan denied your request. The Plan says these services cannot be paid as billed.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. The rules also say that that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. This and the remaining codes were also billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Therefore, we decided that the Plan does not have to pay for a general health panel (80050) and other laboratory services (81000, 84153) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the progressive lenses provided on May 19, 2021.

You asked the Plan to pay for the progressive lenses. You say that your policy states no amount out-of-pocket for glasses after cataract surgery. You say that you enclosed proof of payment and you should be reimbursed the full amount. The Plan denied your request. The Plan says only standard frames and lenses are covered.

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. The Plan only covers standard frames and lenses. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the progressive lenses have not been met. Specifically, lens upgrades are not covered. Therefore, we decided that the Plan does not have to pay for the progressive lenses provided on May 19, 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 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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: 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 based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography of the lumbar spine (72131) and computed tomography of the pelvis (72192).
You asked the Plan to pre-approve the CT scan. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the records do not support that the enrollee meets the criteria. Repeat imaging is not supported without results of prior imaging that show a clear reason for it.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the requested items/services is considered medically reasonable and necessary in this case. Our physician reviewer found This patient has severe osteoporosis and due to her recent falls and the consideration of vertebroplasty and sacralplasty, the repeat scans are necessary as part of surgical planning. Obviously her osteoporosis predisposes her to new and progressive fractures and reassessment prior to intervention is necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography of the lumbar spine (72131) and computed tomography of the pelvis (72192).
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 GeneSight Psychotropic Assay rendered on November 2, 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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed adjacent to the CPT code for GeneSight testing. 

We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX Z-Code. 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 GeneSight Psychotropic Assay rendered on November 2, 2020.