Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for outpatient mental health services provided on February 25, 2021.  You asked the Plan to pay for the outpatient mental health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. Medicare rules say that clinical psychology services must be provided by a clinical psychologist with a doctoral degree in psychology who is licensed and certified by the state.   We looked at the file and Medicare rules. The file shows that the provider has an EDD (Doctor of Education) degree and not a doctorate in psychology. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that he is not currently receiving but that would be available at the LTACH facility.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided July 9, 2021.  You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the records do not support the billed services.  The Plan follows Medicare rules. Medicare rules say that definitive drug testing panel orders should be individualized based on clinical history and risk assessment and must be documented in the medical record.  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 lab services. Our reviewer says that the lab services were not medically necessary. Our physician reviewer found the records did not reveal a prior abnormal or unexpected urine drug screening test or report of signs of abuse or an explanation for testing so many drug classes that are not applicable to this patient.  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 lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided July 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Prolia.  You asked the Plan to pre-approve Prolia. You say that in a head-to-head trial, Prolia had a larger increase in bone mineral density compared to alendronate. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of a bisphosphonate before it will approve Prolia.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of a bisphosphonate. The records do not show that this drug would likely be less effective and/or have adverse effects for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).  You asked the Plan to pre-approve TMS therapy. You say that the enrollee has tried and failed four antidepressants as well as psychotherapy. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the notes do not indicate that other treatments were tried and were not successful, or that at least 4 different antidepressants of at least 2 different classes and 12 weeks of psychotherapy were tried.  The Plan must follow Medicare rules. Medicare rules say that TMS therapy may be covered under certain clinical conditions. Medicare rules say that for Medicare to consider coverage for any service, the information submitted by the provider must corroborate the documentation in the beneficiary's medical records and confirm that coverage criteria have been met.  We looked at the file and Medicare rules. No supporting medical records have been submitted with this request. Without supporting medical records, it cannot be determined whether the enrollee meets the clinical criteria for the requested use of TMS therapy. Therefore, your request does not corroborate the beneficiary's medical records and confirmed that coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of TMS therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673), provided on June 15, 2021.  You asked the Plan to pay for a pneumatic compression device. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  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 and E0673), provided on June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inversion table (E1399) and sales tax (S9999), purchased on May 18, 2021.  You asked the Plan to pay for the inversion table and sales tax. You say that you need this item. The Plan denied your request. The Plan says this item would be useful to a person absent of illness or injury.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inversion table and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the inversion table (E1399) and sales tax (S9999), purchased on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the determination of refractive state (92015) provided July 12, 2021.  You asked the Plan to pay for the eye refraction. You say that you disagree with the denial. The Plan denied your request. The Plan says this service is not covered because it was not obtained from a provider in the Plan's vision network. 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 covers these services when they are provided by a network vision provider.  We looked at the file and the Plan's rules. In this case the eye refraction was not performed by a network vision provider. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided July 12, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.  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 the 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications and had stable vital signs. He received physical and occupational therapy and needs supervision to stand-by assist with functional mobility, including gait to 200 feet. He needs varied assist with activities of daily living. He has no skilled nursing or skilled therapy needs. He does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99497) provided on April 20, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.  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 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 the services. Our reviewer says that the use of code 99497 is not supported by the records provided. Our reviewer found that the documentation includes a provider visit performed on April 20, 2021, and reported with CPT 99305, and a progress note, documenting a discussion took place on April 20, 2021. However documentation of time or provider signature is not included in the documentation and therefore, cannot be verified.  We looked at this coder'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 the services (99497) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for cytopathology, fluids, washings or brushings, except cervical or vaginal (88104) special stain including interpretation and report (88312) provided on July 16, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the pathology services. You say that if the referring physician was paid for their services, you should be paid for yours as an ancillary service to their procedure. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 cytopathology, fluids, washings or brushings, except cervical or vaginal (88104) special stain including interpretation and report (88312) provided on July 16, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the protein measurement (84165) provided on April 26, 2021.  You asked the Plan to pay for the protein measurement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 84165 has an MUE value of 1 and 2 units were billed.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 84165 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the protein measurement have not been met. Therefore, we decided that the Plan does not have to pay for the protein measurement (84165) provided on April 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on July 12, 2021.  You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient.  We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan (70450) provided on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an MRI scan of the brain (70553) provided on July 10, 2019.  You asked the Plan to pay for an MRI scan of the brain. You say that upon receipt of corrected billing information from the patient you promptly submitted your claim to the Plan. The Plan denied your request. The Plan says rules for payment have not been met because the claim was not filed timely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for an MRI scan of the brain was not filed until July 20, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an MRI scan of the brain (70553) provided on July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (33208, 33225) provided on August 28, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the surgical payment.  The Plan must follow Medicare rules. Medicare rules say that payment for the referenced service is included in the payment for the global surgical procedure.   We looked at the file and Medicare rules. In this case, payment for the requested service (33208) is included in the payment for the surgical procedure provided on August 26, 2021. Separate payment cannot be made for this service. As the primary procedure (33208) is not payable in this case, the add-on code (33225) is also no payable. 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 the services (33208, 33225) provided on August 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on June 21, 2021.  You asked the Plan to pay for the subsequent hospital care. You say that the subsequent and second hospitalist visit was justified by member's deteriorated condition. The Plan denied your request. The Plan says the benefit for this service is included in the allowance for another service that has already been adjudicated.  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 99233 is not supported in the record. Specifically, the record shows that another evaluation and management code was paid for a provider in the same group with the same specialty on the same date of service. If more than one evaluation and management service is provided on the same day to the same patient by more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. The documentation submitted does not indicate that these services were for unrelated problems. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on June 21, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home sleep test (G0399).  You asked the Plan to pre-approve the home sleep test. You say that you have lost a fair amount of weight with no sleep. You also say that this service was approved in 2020, and you do not understand why it was approved then but denied now when you are in a worse condition. The Plan denied your request. The Plan says this request is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a single PSG or Home Sleep Test (HST) can diagnose adult OSA. However, if the beneficiary's treating physician has good reason to believe that the result of an HST is insufficient in light of the beneficiary's clinical findings, a subsequent diagnostic PSG could be performed. Such retest decisions would be made on a case-by-case basis. The routine use of a two test routine (HST followed by PSG) to diagnose sleep apnea would not be considered reasonable and 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 home sleep test. Our reviewer says that there is no documentation that you meet the Local Coverage Determination (LCD) criteria for coverage of a repeat Home Type III Sleep test. Our physician reviewer found the records do not document recent surgical treatment, substantial weight loss, substantial weight gain, insufficient clinical response to treatment with continuous positive airway pressure (CPAP) or that the initial CPAP was not tolerated and bilevel positive airway pressure (BPAP) is to be used in lieu of CPAP.  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 home sleep test have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep test (G0399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a crown (D2740) for tooth #20.  You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the tooth does not appear to have significant breakdown.  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 crown 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 crown. Our reviewer says that given the lack of damage to the tooth structure, there would be no medical necessity for a crown on tooth #20. Our physician reviewer found on the provided x-rays it appears tooth #20 has two small occlusal pit restorations in place and no obvious decay or fracture on the remainder of the tooth. Our reviewer found that the selection of crown as a restoration is usually based on the need to provide strength for the tooth by full coverage of the cusps and occlusal portion of the tooth. Our physician reviewer also found that in this case there is 90% of the tooth structure remaining and not clear need to cut down and prepare the tooth for placement of a full coverage restoration.  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 crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for tooth #20.