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

 We decided that the Plan has to pay for the individual psychotherapy services (90837) provided September 29, 2021.  You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly reflect the medical necessity of the services rendered. The Plan denied your request. The Plan says that service is not supported without the required documentation.  The Plan must follow Medicare rules. The rules say that if consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. This does not apply if the physician referred the patient to the CP.  We looked at the file, and Medicare rules. The submitted claim includes a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for the individual psychotherapy services (90837) provided September 29, 2021.   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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Ranibizumab injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation provide does not indicate that the enrollee has one of the diagnoses needed to meet criteria for administration of this drug.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the records do not document a medically-accepted diagnosis for use of the Ranibizumab. Medically-accepted uses for intraocular ranibizumab include wet age-related macular degeneration, macular edema following retinal vein occlusion, diabetic macular edema, diabetic retinopathy or myopic choroidal neovascularization. The records do not document the enrollee has any of these accepted diagnoses.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Ranibizumab injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgery services.  

You asked the Plan to pre-approve surgery services. You say that this surgery is medically necessary. The Plan denied your request. The Plan says this service is non-covered according to Medicare rules. 

 The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  

We looked at the file and Medicare rules. In this case, no medical records were provided to establish the medical necessity of the requested procedure. The Plan sent several requests to your provider, but no records were returned. Based on this information, we decided that Medicare rules for coverage of surgery services have not been met. Therefore, we decided that the Plan does not have to pre-approve surgery services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve bioimpedance spectroscopy (BIS) (93702).
You asked the Plan to pre-approve BIS. You say that this is medically necessary. The Plan denied your request. 
The Plan says that this is experimental.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 BIS. Our reviewer says that the 
requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found BIS provides a more precise identification of patients likely to benefit from an early compression 
intervention compared to other options.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of BIS have been met. Therefore, we decided that the Plan has to pre-approve
bioimpedance spectroscopy (BIS) (93702).
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: 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 a home sleep test. You say that the requested service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage.  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 a home sleep test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has obstructive sleep apnea (OSA), diagnosed on a home sleep study in 2016. She tried auto-titrating continuous positive airway pressure (CPAP) but was unable to tolerate it. She is not willing to come to a sleep lab for an attended sleep study or positive airway pressure titration. The diagnosis of OSA is not in question, so a repeat diagnostic sleep study is 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 a 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee has no skilled nursing or therapy needs that can only be provided on an inpatient basis.  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 SNF services. Our physician reviewer found that the enrollee does not require the services of a skilled professional nurse to provide medically necessary treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. Her functional level does not require the services of a qualified therapist to provide medically necessary treatment. She does not require skilled nursing or therapy services on a daily basis. She does not require necessary services on an inpatient basis, in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a stair lift.
You asked the Plan to pay for a stair lift. You say that you were told by a plan representative that if you obtained a script from your doctor, then the item would be partially or fully covered. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift 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 pay for a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage 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. In this case, the Plan has sent multiple requests for medical records to support the requested CGM. No records were provided to indicate whether the specific CGM criteria have been met. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lower partial denture (D5212), an upper partial denture (D5211), and fillings (D2332, D2393 x2) to be provided by an out-of-network provider.  You asked the Plan to pre-approve a lower partial denture, an upper partial denture, and fillings to be provided by an out-of-network provider. You say that the services are medically necessary. The Plan denied your request. The Plan says the services at issue are not covered when provided by an out-of-network provider.  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.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a lower partial denture, an upper partial denture, and fillings to be provided by an out-of-network provider have not been met. Specifically, the services at issue are not covered when provided by an out-of-network provider. Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5212), an upper partial denture (D5211), and fillings (D2332, D2393 x2) to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve crowns - porcelain fused to high noble metal (D2750) for teeth 24 and 25.  You asked the Plan to pre-approve crowns for teeth 24 and 25. You say that you would like crowns covered for teeth 24 and 25. The Plan denied your request. The Plan says that the x-rays provided do not show that a crown is needed to fix your teeth.  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. In this case the Plan provided a poor-quality photocopy of the x-rays used to make a decision in their original appeal submission. We requested diagnostic quality x-rays for review. A response to our request was not received. The Plan has failed to provide the necessary documentation that would support denial of this service. Therefore, we decided that the Plan has to pre-approve crowns - porcelain fused to high noble metal (D2750) for teeth 24 and 25.   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 pre-approve a surgical placement of implant body: endosteal implant
(D6010).
You asked the Plan to pre-approve the endosteal implant. You say that tooth #31 had severe decay with abscess
and due to the severe infection, the enrollee could not get numb. You also say that the enrollee was referred to
an oral surgeon for the removal of tooth #31. The Plan denied your request. The Plan says this service is not
covered under the enrollee's 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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
surgical placement of implant body: endosteal implant (D6010).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a physical therapy visit (97163) provided 
on June 28, 2021.
You asked the Plan to waive the coinsurance for the physical therapy visit. You say that the services should be 
covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 
provided.
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 15% 
coinsurance for Outpatient Rehabilitation Services. 
You have been asked to pay a 15% coinsurance for a physical therapy visit (allowed is $98.12 x 15% = 
$14.72). Physical therapy visits fall within the Outpatient Rehabilitation Services benefit category. 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 coinsurance for a physical therapy visit (97163) provided on June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99239) provided July 4, 2021.
You asked the Plan to pay for the physician services. You say that the physician services were medically
necessary. The Plan denied your request. The Plan says the documentation does not support the code billed.
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 99239 is hospital discharge day management of more
than 30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not document
how much time was spent performing this service. Based on this information, we decided that Medicare rules
for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to
pay for physician services (99239) provided July 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and take home drugs (D9630) provided on October 20, 2021.
You asked the Plan to pay for the limited oral evaluation and take home drugs. You say that you are allowed 3 extractions per year. You say this is the first extraction you have had, and it should be covered. You say that a comprehensive oral evaluation is covered, so limited oral evaluation should be covered too. You say that nitrous oxide is covered. You also say that medicines should be covered as part of the procedure. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that take home drugs is not listed as a covered service either.
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 limited oral evaluation (D0140) and take home drugs (D9630) provided on October 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the spinal injection provided on October 18, 2021.  You asked the Plan to pay for the spinal injection. You say that this treatment is deemed necessary for the enrollee's condition. The Plan denied your request. The Plan says no records were submitted to support medical necessity.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. No medical records were submitted with the file. As such, it cannot be determined whether coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the spinal injection have not been met. Therefore, we decided that the Plan does not have to pay for the spinal injection provided on October 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) and the duplex scan of the extracranial arteries; complete bilateral study (93880) rendered by the out-of-network (OON) provider on May 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiography (93306) and the duplex scan of the extracranial arteries; complete bilateral study (93880) rendered by the out-of-network (OON) provider on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the nail debridement (11720) and the nail trimming (G0127) rendered by the out-of-network (OON) provider on October 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the nail debridement (11720) and the nail trimming (G0127) rendered by the out-of-network (OON) provider on October 12, 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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 are receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.
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.