Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided following a
total knee arthroplasty (27447).
You asked the Plan to pre-approve acute inpatient hospital care. You say that you have no one to help look
after you following your surgery and would benefit from inpatient care. The Plan denied your request. The Plan
says based on Medicare guidelines and the information provided about your current condition, an inpatient
admission is not medically necessary following your surgical procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more. 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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found you are stable and have been provided medical clearance to undergo this
procedure. The planned procedure, identified by code 27447, is not listed in the Medicare Inpatient Only List.
This procedure is currently approved as an ambulatory procedure. There is no documentation provided to
support the expectation that you will require a greater than two-midnight stay following your procedure. The
record does not show that at the time of inpatient admission, the admitting physician would reasonably expect
that your necessary hospital care would span the necessary two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care to be provided following a total knee
arthroplasty (27447).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E2311, E2313, E2331). You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's function in the upper extremities with the ability to feed herself and that she "demonstrates sufficient and effective functional grasp with bilateral hands in order to safely and independently manage a manual joystick controller" supports that the enrollee can control any power options on her approved Group 3 power wheelchair through their own individual switches. E2331 is not medically necessary, as it exceeds the enrollee's medical need. The enrollee can independently control the power mobility device; therefore, E2331 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2377, E2311, E2313, E2331).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for WATS3D testing provided on February 3, 2021.
You asked the Plan to pay for lab testing. You say that the ordering physician made a professional determination of medical necessity for this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this testing was not medically necessary.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network physician. The file does not show that the plan provided notice that lab testing would not be covered. Under Medicare rules, this means lab testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for WATS3D testing provided on February 3, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 6, 7, 8, 9, 10, 11, and 13.
You asked the Plan to pre-approve the crowns. You say that you need these crowns to help prevent infection in your jaw. You also say that you need reconstructive jaw surgery and must have your teeth crowned prior to this surgery. The Plan denied your request. The Plan says the panoramic x-ray is not clear and does not show why crowns were 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 crowns when the services are medically necessary and reasonable. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the crowns. Our reviewer says that there is no medical necessity for the requested crowns. Our physician reviewer found there is no supporting information as to the status of the existing crowns on tooth #'s 11 and 13, nor is there any narrative as to the clinical need for crowns on tooth #'s 6, 7, 8, 9, and 10 due to breakdown or caries. The supplied panoramic x-ray does not clearly show any substantial breakdown of tooth #'s 6, 7, 8, 9, and 10. Crowns may be considered where there is substantial loss of structure, a fracture, or risk of imminent fracture. Our reviewer also found that there is no clear indication of any of the common indications for crowns, and no narrative to support the requested treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740) for tooth #'s 6, 7, 8, 9, 10, 11, and 13.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the 6 additional PT visits and 7 additional HHA visits in the home.
You asked the Plan to pre-approve the additional PT and HHA visits. You say that the enrollee can only support 85 pounds and needs additional PT visits. The Plan denied your request. The Plan says the visits previously approved should be sufficient for the enrollee's issues and to finalize their continuing home exercise education. The Plan also says that the the enrollee has natural support at home and that the HHA is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional PT and HHA visits. Our reviewer says that the requested ongoing home health PT services and HHA services are not shown to be medically necessary or reasonable. Our physician reviewer found the enrollee does not have documented PT needs. The enrollee is walking up to 220 feet and appears to be suitable for a home exercise program or outpatient PT. Our reviewer found that the enrollee does not have documented HHA needs. Our physician reviewer also found that there is no evidence of an illness or injury that is being affected by a HHA. 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 additional PT and HHA visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the 6 additional PT visits and 7 additional HHA visits in the home.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentures.
You asked the Plan to pre-approve the dentures. You say that you would like a reset of the denture benefit. 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. The Plan covers dentures once every five years. Dentures were last received less than five years ago on March 25, 2021, and paid for by the plan. Based on this information, we decided that the Plan's rules for coverage of the dentures have not been met. Therefore, we decided that the Plan does not have to pre-approve dentures.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on February 10, 2021. You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the screening genetic testing is not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular gene testing provided on February 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.

You asked the Plan to pre-approve Ilumya. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ilumya. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has moderate to severe plaque psoriasis. The enrollee has failed multiple topical treatments. The documentation does not support that the enrollee has tried and failed Remicade or Inflectra and Stelara. The documentation does not support that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve the bed. You say that the current bed is too high. The Plan denied your
request. The Plan says there is no indication of a need for a certain position while in bed.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered
medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation from
your treating medical provider does not clearly reveal that your condition has failed positioning of the bed in
ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The
documentation does not support a need for frequent or an immediate change in body position or special
attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not
medically necessary for you.

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 bed have not been met. Therefore, we decided that the Plan does not have to
pre-approve a semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2391, D2331, D2330) provided April 12, 2021.

You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the provider that rendered these services is not eligible for Medicare payment.

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 dental services (D2391, D2331, D2330) provided April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the specialist office visit provided on April 26, 2021.
You asked the Plan to waive the copay for the specialist visit. You say that the provider said he could not help you. The Plan denied your request. The Plan says the claim processed correctly.
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 $35 copay for specialist services. You have been asked to pay a $35 copay for the specialist visit. The visit falls within the physician services benefit category. The copay is not determined by the outcome of services. 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 copay for the specialist office visit provided on April 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device 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 experimental and investigational procedures are not covered by Medicare.

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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging from 2019 has not demonstrated moderate spinal stenosis the levels requested for treatment. The record indicates that the enrollee has not attempted physical therapy. 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 the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered on April 19, 2021 to April 20, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 

We looked at the file and Medicare rules. Billed procedure codes 99233 (subsequent hospital care) and 99443 (telephone evaluation and management service) are not payable because the Plan previously paid for physician services from a provider in the same group practice for the dates of service at issue. Therefore, we decided that the Plan does not have to pay for the physician services rendered on April 19, 2021 to April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) provided on April 23, 2021.

You asked the Plan to pay for Tdap when administered to individuals 7 years or older, for intramuscular use (97015). You say that your doctor advised you that you should have the shot as the result of a fall. The Plan denied your request. The Plan says the claim was not billed with a diagnosis indicating the immunization was due to treatment of an injury.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tdap when administered to individuals 7 years or older, for intramuscular use (97015). The Plan follows the same rules. 

Records do not show that you were directly exposed to any illness related to Tdap or the immunization was related to the treatment of your injury. The primary diagnosis code is- encounter for immunization. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the procedures coded as 15374, 15002 and 15003 provided October 30, 2020.

You asked the Plan to pay for the procedures coded as 15374, 15002 and 15003. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says medical records are still needed to support the services as 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. 

We find that CPT code 15374, 15002 and 15003 is not supported in the medical record. Specifically, the records that were submitted do not include a complete objective description of the procedures rendered. Based on this information, we decided that Medicare rules for coverage of the procedures coded as 15374, 15002 and 15003 have not been met.

Therefore, we decided that the Plan does not have to pay for the procedures coded as 15374, 15002 and 15003 provided October 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 15, 2021, to April 7, 2021.

You asked the Plan to pay for the dental services. You say that you were assured the services would be paid. The Plan denied your request. The Plan says the provider chose not to receive Medicare funds.

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. The records show that the provider was not eligible to provide services under Original Medicare at the time the services were provided. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 15, 2021, to April 7, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on July 21, 2020.

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 99285 is "Emergency department visit for the evaluation
and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and Medical decision making of high complexity. Counseling and/or coordination of care with
other physicians, other qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs.

Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or
physiologic function".

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 99285 is
not supported by the records provided. Our reviewer found that the emergency room visit supports a
comprehensive history and exam. However, the documentation also supports medical decision making of
moderate complexity (with labs x-ray and prescription medication). Therefore, the documentation supports
level CPT 99284.

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 (99285) provided on July 21, 2020.