Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Partially Favorable

 We decided that the Plan has to pay for the laboratory services billed with CPT codes 81301 and 81194. We decided that the Plan does not have to pay for the laboratory services billed with CPT codes 81455 and 81436.   You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan says that the submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11.  We decided that the Plan has to pay for the laboratory services billed with CPT codes 81301 and 81194.   The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any evidence as to why the laboratory services billed CPT codes 81301 and 81194 are not eligible for payment. The Plan has not indicated why these codes do not meet National or Local Coverage Determination criteria or why these services are considered unbundled. It is the burden of the Health Plan to substantiate their denial with evidence. The denial for these services has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the laboratory services billed with CPT codes 81301 and 81194.   We also decided that the Plan does not have to pay for the laboratory services billed with CPT codes 81455 and 81436.  The Plan follows Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.  We looked at your request, the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage have not been met. Specifically, these services were billed with the laboratory place of service code while the record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services billed with CPT codes 81455 and 81436.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for bite-wing x-rays (D0270) provided on July 8, 2021.  You asked the Plan to pay for bite-wing x-rays. You say that prior and after your appointment, you were told the x-rays would be covered. The Plan denied your request. The Plan says you are covered for bite-wing x-rays once in a calendar year. The Plan also says you had a full set of x-rays completed on July 9, 2021. That claim was received prior to the July 8th claim.  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 bite-wing x-rays once per calendar year.   We looked at the file and Medicare rules. The records show that you received a full set of mouth x-rays on July 9, 2021. The records also show the claim for July 9, 2021 was received prior to the claim for July 8, 2021; therefore, when your claim for July 8, 2021 was submitted, your maximum allowed benefit for bite-wing x-rays was exhausted. Based on this information, we decided that the Plan's rules for coverage of bite-wing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for bite-wing x-rays (D0270) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing (0278T) and acupuncture (97810) provided on July 7, 2021.  You asked the Plan to pay for the transcutaneous electrical modulation pain reprocessing and acupuncture. You say that you would like reconsideration because you would like to be able to continue with this treatment. The Plan denied your request. The Plan says this service is considered investigational.  The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.     We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing (0278T) and acupuncture (97810) provided on July 7, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 We decided that the Plan has to pre-approve the crown (D2752). We decided that the Plan does not have to pre-approve the pontic (D6242) and retainer crowns (D6752).   You asked the Plan to pre-approve the crown (D2752), pontic (D6242) and retainer crowns (D6752). The Plan denied your request. The Plan says that the services are not covered benefits.    We decided that the Plan has to pre-approve the crown (D2752).   The dental coverage submitted clearly shows that crowns and crown repairs (D2740, D2751 and D2752) are covered for anterior teeth. Tooth #9 is an anterior tooth. Therefore, we decided that the Plan has to pre-approve the crown.   We also decided that the Plan does not have to pre-approve the pontic (D6242) and retainer crowns (D6752).  The dental coverage submitted does not list these services as covered benefits. Therefore, we decided that the Plan does not have to pre-approve the pontic (D6242) and retainer crowns (D6752).  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four (4) additional PT visits.  You asked the Plan to pre-approve four (4) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is 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 four (4) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and 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 by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's 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 four (4) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional PT visits.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pre-approve a repeat colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing (45378).  You asked the Plan to pre-approve a repeat colonoscopy flexible, diagnostic. You say that had a polyp removed on your last colonoscopy 5 years ago and you are worried to wait 2 years for another colonoscopy. The Plan denied your request. The Plan says that there are no high-risk surveillance criteria for this member cited.  The Plan follows Medicare rules. Medicare rules say that Medicare covers an evaluation within 6 months of the removal of sessile polyps to determine and document total excision. If evaluation indicates that residual polyp is present, excision should be done with repeat colonoscopy within 6 months. After evidence of total excision without return of the polyp, repeat colonoscopy yearly.  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 repeat colonoscopy flexible; diagnostic. Our reviewer says that a repeat colonoscopy flexible; diagnostic is medically necessary. Our physician reviewer found that Medicare criteria supersede the evidence-based eviCore guidelines as provided. Medicare thus approves the 5-year surveillance interval requested in your case.   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 repeat colonoscopy flexible; diagnostic have been met. Therefore, we decided that the Plan has to pre-approve a repeat colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing (45378).   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services received on July 23, 2021.  You asked the Plan to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services. You say that you have tried other treatments and nothing else has helped. The Plan denied your request. The Plan says the services received 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 pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have polyneuropathy. You received Scrambler therapy for her pain. The services received are considered an experimental/investigational procedure. Therefore, you did not meet criteria for the services received.  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 transcutaneous electrical modulation pain reprocessing (TEMPR) services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services received on July 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you need proper rehabilitation. The Plan denied your request. The Plan says your request for approval of an IRF admission does not meet the requirements for approval.    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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a dental bridge comprised of a false tooth (D6240) for tooth #30 and retainer crowns (D6750) for teeth #29 and #31.  You asked the Plan to pre-approve the dental bridge. You say that this service is necessary, and you are experiencing pain in your gums. The Plan denied your request. The Plan says the criteria for the fixed prosthesis are not met, and as such this service 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 placement of a fixed prosthetic appliance only for the anterior (front) segment of the mouth in those exceptional cases where there is a documented physical or neurological disorder that would preclude placement of a removable prosthesis, or in those cases requiring cleft palate stabilization. We looked at the file and the Plan's rules. The bridge is requested for the posterior (back) segment of the mouth. Based on this information, we decided that the Plan's rules for coverage of the dental bridge have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental bridge comprised of a false tooth (D6240) for tooth #30 and retainer crowns (D6750) for teeth #29 and #31.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) additional PT visits.  You asked the Plan to pre-approve eight (8) additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is 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 eight (8) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and 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 by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist 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 eight (8) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing (0278T) and acupuncture (97810) provided on July 8, 2021.  You asked the Plan to pay for the transcutaneous electrical modulation pain reprocessing and acupuncture. You say that you would like reconsideration because you would like to continue with this treatment. The Plan denied your request. The Plan says this service is considered investigational.  The Plan must follow Medicare rules. Medicare rules say that payment may be made for implanted peripheral nerve stimulators in which electrodes are surgically placed under the skin around a nerve. The rules also say that acupuncture is only covered when provided for low back pain when furnished by a licensed acupuncturist.     We looked at the file and Medicare rules. We find that this device does not meet the Medicare definition for an implanted nerve stimulator because the device involves needles inserted around the nerves and not electrodes being surgically implanted. The Food and Drug Administration (FDA) clearances for devices of this type are as electro-acupuncture devices. Since acupuncture is not covered by Medicare for any condition when rendered through a device rather than by a licensed practitioner, we find that Medicare coverage criteria for this auricular stimulator have not been met. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical modulation pain reprocessing (0278T) and acupuncture (97810) provided on July 8, 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 it's imperative to get strength back in your left arm. The Plan denied your request. The Plan says an admission to an inpatient rehabilitation facility 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 the enrollee was admitted for cervicothoracic spine surgery. The current medical problems are stable and there are no complex nursing or rehabilitation needs.     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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a referral to an out-of-network facility for computed tomography (CT) scan of the chest.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there is an in-network option.  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 a referral to an out-of-network facility for computed tomography (CT) scan of the chest.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a repeat facet joint radiofrequency ablation procedure (64633, 64634).  You asked the Plan to pre-approve the ablation procedure. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that if there is an extended time, two years or more, since the last ablation procedure and/or there is a question as to the source of the recurrent pain, then diagnostic procedures must be repeated.  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 ablation procedure. Our reviewer says that the services are not medically necessary. Our physician reviewer found more than two years has passed since the last ablation procedure. Diagnostic procedures must be repeated before a repeat ablation procedure can be performed.  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 ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat facet joint radiofrequency ablation procedure (64633, 64634).