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

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from March 8, 2021, to March 16, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the hospital record does not support reporting a diagnosis of metabolic encephalopathy. 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.    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 the services at issue in this case were not supported by the medical records. Our physician reviewer found the enrollee was admitted to the hospital with hyperglycemia. Glucose was 642. She was reported as awake and alert with a Glasgow Coma Scale (GCS) of 13-14 due to speech and failure to follow instructions. The score was later 15. She was treated for hyperosmolar hyperglycemic syndrome vs diabetic ketoacidosis. Meningitis was ruled out but was started on antibiotics during workup. Metabolic encephalopathy was listed as a diagnosis. The definition of metabolic encephalopathy was not met as the enrollee was alert and oriented and had a near normal GCS. Therefore, the submitted diagnosis code and DRG is not supported by the documentation.   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 inpatient hospital services provided to the enrollee from March 8, 2021, to March 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided May 28, 2021.

You asked the Plan to pay for the periodontal maintenance. You say that you were told you had dental coverage when you signed up. The Plan denied your request. The Plan says this service is not covered under your benefits.

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 periodontal maintenance (D4910) provided May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with an out-of-network (OON) psychiatry/neurology specialist.

You asked the Plan to pre-approve specialist treatment. You say that the providers the Plan recommends are not specialists in treatment of your disease. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network provider.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

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 specialist treatment. Our reviewer says that you do not meet the Medicare criteria for treatment with an out-of-network provider. Our physician reviewer found you can safely be treated by an in-network physician who is credentialed and clinically maintained by the Plan. There is nothing unique about your condition that would make it medically necessary for you to see an out-of-network provider. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of specialist treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with an out-of-network (OON) psychiatry/neurology specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve the scooter. You say that this is medically necessary, as you are unable to
use crutches. The Plan denied your request. The Plan says Medicare has researched that there is not enough
information to prove the safety and effectiveness in the Medicare population to establish the medical necessity
for these products.
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 scooter. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found based upon a review of the published clinical literature, there is insufficient data demonstrating safety
and efficacy of the knee scooter in the Medicare population.
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 knee scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller, harness upgrade, and
electronic connection between wheelchair controller and two or more power seating system motors.
You asked the Plan to pre-approve an expandable controller, harness upgrade, and electronic connection
between wheelchair controller and two or more power seating system motors. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are only 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 an expandable controller, harness
upgrade, and electronic connection between wheelchair controller and two or more power seating system
motors. Our reviewer says that the documentation does not support that the requested items are medically
reasonable or necessary. Our physician reviewer found the documentation does not reveal that the enrollee
requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin
control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee
does not need to operate a separate display (i.e., for alternate control devices), other electronic devices (e.g.,
control of an augmentative speech device or computer through the chair's drive control), or an attendant
control. The approved wheelchair has power tilt, recline, and power elevating leg rests but the enrollee's
strength and function in the upper extremities with the ability to feed self independently supports that the
enrollee can control any power options through their own individual switches. Therefore, the enrollee does not
meet criteria for the requested items.
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 expandable controller, harness upgrade, and electronic connection between
wheelchair controller and two or more power seating system motors have not been met. Therefore, we decided
that the Plan does not have to pre-approve an expandable controller, harness upgrade, and electronic connection
between wheelchair controller and two or more power seating system motors.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Truxima.

You asked the Plan to pre-approve Truxima. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because this is not being
requested for a medically accepted indication.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Truxima. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of Truxima. Our physician reviewer found
Truxima is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Records do not show
that the Truxima will be used in combination with methotrexate or that the enrollee has had an inadequate
response to one or more tumor necrosis factor-antagonist therapies. The requested use of Truxima is not
supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved
medical journal.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Truxima have not been met. Therefore, we decided that the Plan does not have
to pre-approve use of Truxima.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee orthosis.

You asked the Plan to pre-approve a knee orthosis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a knee orthosis is only 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 knee orthosis. Our reviewer says that the documentation does not support that the requested item is medically reasonable or necessary. Our physician reviewer found the enrollee has right knee pain and difficulty walking with complaints of knee instability and buckling. There is no documentation that the enrollee meets Medicare criteria for medical necessity for the requested knee orthosis. Records report a history of knee instability and buckling but no physical examination is recorded which confirms this. There is no record of a recent injury or surgery to the knee to qualify for the requested device. Therefore, the enrollee does not meet criteria for the requested item. 

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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left knee genicular nerve radiofrequency ablation (RFA).  You asked the Plan to pre-approve a left knee genicular nerve radiofrequency ablation (RFA). 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. 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 left knee genicular nerve radiofrequency ablation (RFA). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic left knee pain. Genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The enrollee does not meet criteria for the requested 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 a left knee genicular nerve radiofrequency ablation (RFA) have not been met. Therefore, we decided that the Plan does not have to pre-approve a left knee genicular nerve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve block.  You asked the Plan to pre-approve the requested services. You say that the cooled lesioning is much more accurate and effective. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in peer-reviewed literature.  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 requested services. Our physician reviewer found that the enrollee has right knee osteoarthritis. She is taking Ibuprofen and Tylenol for pain. She has tried physical therapy and has had intra-articular injections of steroids and viscosupplements. The requested nerve block is considered an experimental/investigational therapy. It's role in treating osteoarthritis of the knee has not been clarified yet.  Therefore, the request is considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the limited oral evaluation - problem focused (D0140)
and intraoral - periapical first radiographic image (D0220) provided July 26, 2021.
You asked the Plan to pre-approve the limited oral exam and intraoral - periapical first x-ray. You say that you
needed emergency dental treatment. The Plan denied your request. The Plan says your dental claims have been
reprocessed; however, you have exceeded frequency limits for the limited oral exam and intraoral x-rays.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the limited
oral exam once per calendar year and the intraoral - periapical first x-ray once per calendar year.
We looked at the file and Medicare rules. The Plan provided documentation showing that a limited oral exam
and intraoral x-rays were previously covered on January 27, 2021. Based on this information, we decided that
the Plan's frequency limits for coverage of the limited oral exam and intraoral x-rays have been exceeded.
Therefore, we decided that the Plan does not have to pre-approve the limited oral evaluation - problem focused
(D0140) and intraoral - periapical first radiographic image (D0220) provided July 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower denture adjustment (D5411).
You asked the Plan to pre-approve a lower denture adjustment. You say that the services are necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit.
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 lower denture adjustment (D5411).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam chest 1 view (CPT code 71045) provided to the enrollee on August 5, 2021.

You asked the Plan to pay for the chest x-ray. You say that the claim should be paid. The Plan denied your request. The Plan says this is a duplicate of previously processed claims.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

Review of the file shows that this service was previously paid on August 18, 2021, and there is no additional documentation supporting an additional study which was billed by this provider. The documentation provided shows there was an x-ray performed on August 5, 2021, at 5:28am by this provider, and this service was paid by the Plan. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray exam chest 1 view (CPT code 71045) provided to the enrollee on August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, molar tooth (excluding final
restoration) (D3330) provided on July 22, 2021.
You asked the Plan to pay for the root canal. You say that you were told you had dental coverage when you
signed up for the Plan. The Plan denied your request. The Plan says this service is not covered under your
benefits.
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
endodontic therapy, molar tooth (excluding final restoration) (D3330) provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140)
provided July 20, 2021.

You asked the Plan to pay for the limited oral exam. You say that you were told you had dental coverage when
you signed up for the Plan. The Plan denied your request. The Plan says this service is not covered under your
benefits.

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
limited oral evaluation - problem focused (D0140) provided July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on May 6, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that you need this item. The Plan denied your request. The Plan says this device is not covered when used as a preventative treatment during or after a surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine and administration provided on August 2, 2021.

You asked the Plan to pay for the shingles vaccine and administration. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says they have overturned their denial for payment for all services with the exception of the shingles vaccine and administration. The shingles vaccine is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine and administration. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and administration provided on August 2, 2021. Benefits for the shingles vaccine and administration may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.