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

 We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the left shoulder.  You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the requested MRI is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the MRI.  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 reviewer says that detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures for the left shoulder. Our physician reviewer found exam findings do not demonstrate significant red-flags to proceed with imaging prior to conservative treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.  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 Magnetic Resonance Imaging (MRI) of the left shoulder.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) and assessment of a patient (D0191) provided July 26, 2021.  You asked the Plan to pay for the emergency dental pain treatment and assessment. You say that you cannot afford the cost of the services and would like the Plan to provide coverage. The Plan denied your request. The Plan says these services are not covered under your dental benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the palliative (emergency) treatment of dental pain - minor procedure (D9110) and assessment of a patient (D0191) provided July 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the group two standard power wheelchair (PWC) (K0823).  You asked the Plan to pre-approve the group two standard power wheelchair. You say that you need this item. The Plan denied your request. The Plan says you do not meet the criteria for this wheelchair.  The Plan follows Medicare rules. Medicare rules say that a Group 2 PWC is covered if all the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary's weight. K0823 has a weight capacity up to and including 300 pounds.    The file shows that you do not have a mobility deficit that impairs your participation in MRADLs, your condition can be improved by a walker, cane or manual wheelchair and your weight exceeds the maximum limit for the requested power wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve the group two standard power wheelchair (PWC) (K0823).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the laboratory work provided on July 19, 2021.  You asked the Plan to waive the deductible for the laboratory work. You say that the laboratory work is preventive and should be included as a part of your annual wellness visit and physical. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $125 deductible which applies to laboratory work.   The laboratory work you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $125 deductible that applies towards laboratory work. The record shows the laboratory work is considered a separate service. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on July 19, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the laboratory work provided on July 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.  You asked the Plan to pre-approve a power seat elevation feature. You say that the enrollee needs a wheelchair with seat elevator to adjust position in more than 3 positions to relieve pressure on pressure wound. The Plan denied your request. The Plan says that power seat elevation system is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine supplies (A0398 and A0999) provided on June 22, 2020.  You asked the Plan to pay for the routine supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of the services at issue.  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 A0398 is ALS routine disposable supplies. The CPT Code Manual definition of code A0999 is unlisted ambulance service.  We find that CPT code A0398 and A0999 is not supported in the medical record. Specifically, payment for these services is included in the base rate per the ambulance fee schedule. Based on this information, we decided that Medicare rules for coverage of the routine supplies have not been met. Therefore, we decided that the Plan does not have to pay for the routine supplies (A0398 and A0999) provided on June 22, 2020.
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 prefer to be admitted to acute rehab because you were independent and active before your hospitalization. The Plan denied your request. The Plan says that your medical and therapy needs could be met in a skilled nursing unit.  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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for cellulitis of bilateral lower extremities. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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 pay for the intraoral x-rays (D0220 and D0230) provided on July 27, 2021.  You asked the Plan to pay for the intraoral x-rays (D0220 and D0230). You say that you were not aware the x-rays weren't covered services. You say that you are facing major issues with your husband's health and are asking for the issue to be resolved. The Plan denied your request. The Plan says the services are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-rays (D0220 and D0230) provided on July 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the core buildup (D2950) and crowns (D2740) provided on May 20, 2021.  You asked the Plan to pay for the core buildup (D2950) and crowns (D2740). You say that you were never notified of the change in plan and never authorized for the change. You say that you are living on a fixed income and feel like this is taking advantage of an elderly person. The Plan denied your request. The Plan says the services are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.    Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup (D2950) and crowns (D2740) provided on May 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the replacement prosthesis to be provided by an OON provider.  You asked the Plan to pre-approve the replacement prosthesis. You say that the enrollee is a great candidate for your technology. The Plan denied your request. The Plan says the provider is out-of-network.  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 the replacement prosthesis to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823) with battery (E2365).  You asked the Plan to pre-approve a Group 2 standard power wheelchair with battery. You say that the requested power wheelchair is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested item have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file does not show that the enrollee can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power wheelchair (K0823) with battery (E2365).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 18, 2020.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on March 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia (D9230) provided by an out-of-network provider on December 4, 2020.  You asked the Plan to pay for inhalation of nitrous oxide/analgesia. You say that you went to an in-network provider. The Plan denied your request. The Plan says this is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for inhalation of nitrous oxide/analgesia (D9230) provided by an out-of-network provider on December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endoscopic spinal decompression services.  You asked the Plan to pre-approve the requested services. You say that no other surgery is as safe for the enrollee. The Plan denied your request. The Plan says the procedure is considered 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 the requested services. Our physician reviewer found that endoscopic spinal decompression is experimental. More research is needed to show safety and efficacy of the endoscopic technique. Therefore, the requested services are considered not medically reasonable or necessary.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve endoscopic spinal decompression services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion Device.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery to place a Vertiflex Superion Device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on February 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you would like the claim reprocessed and paid. The Plan denied your request. The Plan says no prior authorization was obtained.  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 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 visit provided on February 11, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (64645) provided on May 5, 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.  In this case, the CPT Code Manual definition of code 64645 is "Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)".  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 64645 is not supported by the records provided.   Our reviewer found that the medical records provided do not include sufficient documentation to validated that "Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)" was performed on May 5, 2021.  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 (64645) provided on May 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the right shoulder.  You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the requested MRI is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the MRI.  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 reviewer says that the request for MRI of the right shoulder is not medically reasonable or necessary.   Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures for the right shoulder. Exam findings do not demonstrate significant red-flags to proceed with imaging prior to conservative treatment. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.       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 magnetic resonance imaging (MRI) of the right shoulder.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from June 14, 2020, through June 20, 2020, and billed with a secondary diagnosis code of D62.  You asked the Plan to pay for the inpatient hospital care as billed. You say that the documentation supports the secondary diagnosis code as billed. The Plan denied your request. The Plan says the documentation does not support the secondary diagnosis of acute posthemorrhagic anemia  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 secondary diagnosis code, D62, defined as acute posthemorrhagic anemia. 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 inpatient hospital care as billed. Our reviewer says that the documentation does not support the services as billed. Our physician reviewer found the documentation does not support the treatment for this diagnosis. Subsequent hospital care notes documents this diagnosis, however no treatment was documented.  Discharge summary does not include documentation of posthemorrhagic anemia and what care was provided. Therefore, this diagnosis is not supported, and would not be included in DRG payment.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from June 14, 2020, through June 20, 2020, and billed with a secondary diagnosis code of D62.