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

We decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 13 and 16, and pontics (D6245) for teeth # 14 and 15.

You asked the Plan to pre-approve a fixed bridge. You say that the enrollee needs a new bridge. You say that a fixed bridge is ideal because the enrollee was already functioning and use to a fixed bridge as opposed to a removable partial denture. You also say that the enrollee has an active gag reflex that in no way would allow for a removable partial denture. The Plan denied your request. The Plan says the requested bridge is not medically necessary.

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 fixed bridge when the services are medically necessary and reasonable. 

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 fixed bridge. Our reviewer says that the fixed bridge is not medically necessary. Our physician reviewer found that in this instance, there is a note that the enrollee has a gag reflex issue, and a removable appliance would be a concern.

The reviewer found that there is no indication that the enrollee could not wear any design type of partial denture, as they can be designed to have minimal palatal coverage. The reviewer found that there is no clearly documented failure of an ability to wear an upper partial denture or other appliance. The reviewer found there is 50% bone loss on tooth #16 and therefore would not be considered a reasonable abutment for a fixed bridge due to the periodontal concerns and lack of bone support. Given the Plan provisions and the periodontal concerns of tooth #16, there is no medical necessity for a fixed bridge from tooth # 13 to # 16.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the fixed bridge have not been met. Specifically, the file shows that tooth # 16 has periodontal concerns and a lack of bone support. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6740) for teeth # 13 and 16, and pontics (D6245) for teeth # 14 and 15.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from October 1, 2020, to October 4, 2020.

You asked the Plan to pay an additional amount for the inpatient hospital care. You say that you do not agree with the overpayment review. You also say that the enrollee's diagnosis was coded accurately. The Plan denied your request. The Plan says the provided documentation does not support the billed diagnosis-related group (DRG).

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 principal diagnosis code, A41.9, defined as, sepsis, unspecified organism. 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 an additional amount for the inpatient hospital care. Our reviewer says that in this case, you billed the inpatient care provided with primary diagnosis code, A41.9, sepsis, unspecified organism. Our physician reviewer found that the provided documentation did not support the billing of sepsis, unspecified organism, ICD-10-CM code A41.9.

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. Specifically, the file does not support the billing of the primary diagnosis code of sepsis, unspecified organism. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from October 1, 2020, to October 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 29, forward.
You asked the Plan to pre-approve inpatient psychiatric care from September 29, forward. You say that the
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are
not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 inpatient psychiatric care from
September 29, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient
mental health treatment beyond the date in question of September 29, 2021, forward. Our physician reviewer
found you did not require inpatient mental health treatment beyond September 29, 2021, as you were not a
danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear
that active treatment was taking place beyond the date in question. It did not appear that the services for the
dates in question were reasonably expected or medically necessary to improve your condition or for the
purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from September 29, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 29,
forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 5, 2021.
You asked the Plan to pay for the office visit (99203). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this service is not covered when provided 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 pay for the office visit provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the right knee.
You asked the Plan to pre-approve genicular nerve radiofrequency ablation of the right knee. 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 genicular nerve radiofrequency ablation of the right knee. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is status post Supartz injections. The enrollee underwent genicular nerve blocks two times in the past. Genicular nerve blocks and genicular nerve radiofrequency ablation 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.
Therefore, 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 genicular nerve radiofrequency ablation of the right knee have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation of the right knee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a RevoFit adjustable click prosthetic socket with additions and components.
You asked the Plan to pre-approve RevoFit prosthetic system. You say that a standard prosthesis will not work for the enrollee and the REVO system is needed for his particular care. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because studies have not proven that the REVO system is more effective than a standard prosthesis.
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 RevoFit prosthetic system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested REVO item has not been proven safe and effective for the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RevoFit prosthetic system have not been met.
Therefore, we decided that the Plan does not have to pre-approve a RevoFit adjustable click prosthetic socket with additions and components.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and oral hygiene instructions (D1330), or pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 29, 2021 by an OON provider.
You asked the Plan to pay for the intraoral periapical x-rays and oral hygiene instructions, and to pay more for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you would like to appeal these services. The Plan denied your request. The Plan says the intraoral periapical x-rays and oral hygiene instructions are not covered services. The Plan also says that these services were performed by a non-
participating provider, and you are responsible the coinsurance amount plus any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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 intraoral periapical x-rays and oral hygiene instructions are not among those covered under this benefit. For services received OON you are responsible for a 50% coinsurance for each service plus the difference between the billed and allowed amounts. Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), each additional intraoral periapical x-ray (D0230), and oral hygiene instructions (D1330), or pay more for the periodic oral evaluation (D0120), bitewing x-rays (D0274), and prophylaxis (D1110) provided on January 29, 2021 by an OON provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of a complete maxillary denture (D5750) provided on February 10, 2021.
You asked the Plan to pay for the reline of a complete maxillary denture. You say that your dentures broke, and you opted to have them repaired as opposed to purchasing a new set. The Plan denied your request. The Plan says this service is not covered. The Plan also says that this claim paid correctly, you have been billed appropriately, and the correct amount has been applied.
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 reline of a complete maxillary denture (D5750) provided on February 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal ultrasound coded as 76705 provided May 7, 2021.
You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this code was not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound coded as 76705 provided May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Pacdev (J9177).

You asked the Plan to pre-approve Pacdev. You say that the drug is medically necessary. The Plan denied your request. The Plan says the requested use of this drug is not FDA-approved for the enrollee's diagnosis and its use is not supported by one of the major drug compendia or clinical research.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Pacdev. Our reviewer says that "the drug is not medically necessary. Our physician reviewer found the requested use of this drug is not FDA-approved for the enrollee's diagnosis and its use is not supported by one of the major drug compendia or clinical research. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Pacdev have not been met. Therefore, we decided that the Plan does not have to pre-approve Pacdev (J9177).
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 you are requesting Inpatient Rehab as the enrollee has rehab goals that include returning home with support of his family. Admission to an IRF is required as the enrollee's current needs cannot safely be met at a lesser level of care. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided February 10, 2021.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 97110 is not supported in the medical record. Specifically, the record shows the services were provided in the home setting by a physical therapist. There is a more appropriate CPT code to describe this service (G0151). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81161, 81238, 81407, 81411, 81413, 81414) provided March 22, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all Cardiovascular risk assessment panels, except for the basic lipid panel for symptomatic patients with documented or suspected cardiovascular disease. We looked at the file and Medicare rules. Cardiovascular risk panels are not covered under Medicare rules. 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 (81161, 81238, 81407, 81411, 81413, 81414) provided March 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit (99214) provided on March 31, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office or other outpatient visit. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the office or other outpatient visit (99214) provided on March 31, 2021, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig purchased on November 20, 2020, to December 1,
2020 from a non-certified provider.

You asked the Plan to pay for the wig. You say that your doctor told you the Plan covers wigs. The Plan denied
your request. The Plan says this supplier is not contracted with Medicare

Medicare rules say that for equipment to be covered it must be purchased from a Medicare certified supplier.

To receive payment for covered Medicare items or services a provider or supplier must be enrolled in the
Medicare program. This supplier is not contracted with Medicare. We found no exception that would require
the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the wig purchased on
November 20, 2020, to December 1, 2020 from a non-certified provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 28, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the enrollee did not have a choice in the emergency medical services (EMS) being called. You also say that it is the policy of the facility that if the enrollee falls, they must be checked out by the EMS, and transported if necessary. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit. The Plan also says that if no transport is made, there is no coverage for the ambulance call.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 28, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The record shows that the enrollee refused evaluation, care, and transport by the EMS. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on April 15, 2021.

You asked the Plan to pay for the Zoster shingles vaccine (90750). You say that your doctor recommended this
vaccine. The Plan denied your request. The Plan says this 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 Zoster shingles
vaccine (90750). The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to the Zoster shingles
vaccine (90750). Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on
April 15, 2021.

Benefits for the Zoster shingles vaccine (90750) may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.