Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.

You asked the Plan to pre-approve 10 additional PT visits. You say that the services 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 Medicare pays for medically necessary outpatient 
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve 10 additional PT visits. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your 
condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional 
therapist are required to safely and effectively provide treatment, that the services can be safely and effectively 
performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. You should be 
able to transition to an independent home program at this point. The requested services are not part of a 
maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required 
to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further 
deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 10 additional PT visits have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) and dental cleaning (D1110) provided on August 11, 2021.
You asked the Plan to pay for preventative dental services. You say that you were told by an agent when you signed up for this plan that your usual provider was in-network. The Plan denied your request. The Plan says these services were provided by an out-of-network provider, and therefore are not covered.
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, items or services performed by out-of-network providers are not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) and dental cleaning (D1110) provided on August 11, 2021.
Your complaint about potential misinformation from a plan representative is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychiatric diagnostic evaluation (CPT code 90791) and psychotherapy, 60 minutes with patient (CPT code 90837) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the services. You say that you need regular therapy sessions to ensure you are of sound mind. You state that you have searched for numerous providers but the providers you have contacted for services are out-of-network or are not accepting new patients. You state that you want to continue seeing this therapist as you have established rapport with the provider. The Plan denied your request. The Plan says it was determined that the plan has made several attempts to obtain medical records to support the medical necessity of 90791 and 90837, however, were unsuccessful. The Plan states they were unable to review for medical necessity to establish if the requested authorization can be approved for these services.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

Medical records have not been provided to verify if the services meet medical necessity. Therefore, we decided that the Plan does not have to pre-approve psychiatric diagnostic evaluation (CPT code 90791) and psychotherapy, 60 minutes with patient (CPT code 90837) to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on April 23, 2021.

You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Reader (CPT code K0554).

You asked the Plan to pre-approve the item. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that you are not adjusting your insulin doses based on your blood glucose readings. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre 14 Day Reader (CPT code K0554).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve presumptive urine drug testing provided to the enrollee on January 20, 2021.

You asked the Plan to pre-approve the testing. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 80305-QW (1 unit) remains not supported.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the documentation submitted did not include documentation of laboratory results for the billed date of service; therefore, the billed services cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. The review has determined that the enrollee did not require this testing according to Medicare guidelines. The records did not verify that the testing was actually performed by the correct 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 the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve presumptive urine drug testing provided to the enrollee on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array (CPT code 63650), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee has had this pain for approximately 
eight (8) years that is progressively gotten worse especially over the last 8 months. You state that you 
attempted a trial with a spinal cord stimulator, but the wires moved so you could not complete an adequate trial.
The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's 
records show they do not have screening by a multidisciplinary team to include psychological clearance for the 
procedure.

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 service. Our physician reviewer 
found the criteria not met. There is not psychiatric evaluation prior to stimulator placement.

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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array (CPT code 63650), for the 
enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, thoracic; without contrast material (CPT code 72146), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says there is no history or physical exam or any background (narrative) as to why a MRI is needed to make a treatment decision.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found there has been documented recent encounter with the patient. The thoracic spine films were done over two (2) months ago. No discussion of the need for MRI is in the records. A guess would be that progression of fracture etc. would be the clinical question but no discussion is in the materials provided. Without such a narrative and explanation, the medical necessity of MRI of the thoracic spine has not been established. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the MRI, spinal canal and contents, thoracic; without contrast material (CPT code 72146), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) or 
pay more for the problem focused limited oral evaluation (D0140), panoramic x-ray (D0330), and surgical 
extraction (D7210) provided on August 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the bone replacement graft and to pay more for the problem focused limited oral 
evaluation, panoramic x-ray, and surgical extraction. You say that your health plan brochure shows that crowns 
are covered. You also say that you needed the bone graft for a successful procedure and feel these services 
should be covered. The Plan denied your request. The Plan says these services were rendered by an OON 
provider and there were network providers in the area that could have provided these services. The Plan also 
says that the bone replacement graft is not a covered benefit under your dental plan
.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, bone replacement graft for ridge 
preservation (D7953) is not among those covered under this benefit. You are responsible for a 50% coinsurance 
for a surgical extraction (D7210), plus the difference between the billed amounts and allowed amounts because 
these services were received OON. Therefore, we decided that the Plan does not have to pay for the bone 
replacement graft for ridge preservation (D7953) or pay more for the problem focused limited oral evaluation 
(D0140), panoramic x-ray (D0330), and surgical extraction (D7210) provided on August 20, 2021 by an outof-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667) for the 
enrollee
.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no detailed measurements over time confirming the persistence of the 
lymphedema.

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 device. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the record indicates that the enrollee has severe lymphedema and bilateral venous insufficiency. 
The record does not indicate that the venous insufficiency has been treated and it is noted that the edema may 
improve if it is. A progress note from November 2021 indicates that significant improvement( 12cm and 7 c, 
respectively) has been made with manual compression. The elements of the coverage criteria are not satisfied.

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 device have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a pneumatic compression device (E0651, E0667) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) 
services.

You asked the Plan to pre-approve SI joint RFA services. You say that this procedure is medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says the requested services are considered 
experimental/investigational.

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 SI joint RFA services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found According to the literature, sacral lateral nerve branch blocks and/or 
ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered 
experimental and investigational. Studies completed say that this procedure does not improve outcomes 
compared to standard treatment of SIJ pain. Radiofrequency ablation for denervation, whether performed 
using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not 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 SI joint RFA services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation (RFA) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on March 10, 2021.

You asked the Plan to pay for lab tests. You say that there is no contractual agreement in place which dictates that these tests are included in the dialysis rate. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the record does not show that these tests were unrelated to dialysis so these tests are the responsibility of the dialysis facility and are not separately reportable by the laboratory.

The Plan must follow Medicare rules. Medicare rules say that laboratory services furnished to individuals for the treatment of end-stage renal disease (ESRD) are included in the ESRD prospective payment system (PPS) and are not paid separately. 

We looked at the file and Medicare rules. These tests are included in the ESRD PPS payment made to the dialysis facility, so are not separately payable. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on March 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair for the enrollee.
You asked the Plan to pre-approve a shower chair. You say that this is medically necessary. The Plan denied your request. The Plan says that this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visit. You say that you prefer to see the provider you have seen in the past. The Plan denied your request. The Plan says they have in-network providers available to meet your medical needs.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 27, 2021.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's 
attending or primary care physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an 
attempt to consult with, nor a referral from, the enrollee's attending or primary care physician.

Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 
27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
May 15, 2021, to May 19, 2021.

You asked the Plan to waive the copayment for the inpatient stay. You say that you should not be responsible 
for the cost of this care, because you were dissatisfied with the services provided. The Plan denied your 
request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance 
with your contract.

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 $225 
copayment for each of the first seven days of a Medicare-covered stay. 

You have been asked to pay a $900 copayment for the inpatient stay. 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 the inpatient hospital stay provided from May 15, 2021, to May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a hernia repair procedure (49505) provided on July 16, 2021.
You asked the Plan to pay for a hernia repair procedure. You say that the provider of the services at issue is the only surgeon certified to perform the surgery at issue in the United States. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a hernia repair procedure (49505) provided on July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the cinacalcet and dialysis provided from May 1, 2021, 
through May 29, 2021.

You asked the Plan to pay for the cinacalcet and dialysis. You say that the entire claim was denied due to a 
coding issue. You say that the dialysis is a medical necessity, and the claim should be reviewed for payment.
The Plan denied your request. The Plan says the claim was billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 90999 is unlisted dialysis procedure, inpatient or 
outpatient. the CPT Code Manual definition of code J0604 is cinacalcet, oral, 1 mg, (for ESRD on dialysis).

We find that CPT code 90999 and J0604 are not supported in the medical record. Specifically, payment for 
J0604 is included in the ESRD PPS and separate payment is not made. Billing the AX modifier with CPT code 
J0604 is no longer appropriate. Based on this information, we decided that Medicare rules for coverage of the 
cinacalcet and dialysis have not been met. Therefore, we decided that the Plan does not have to pay for the 
cinacalcet and dialysis provided from May 1, 2021, through May 29, 2021.