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

We decided that the Plan does not have to pre-approve physical therapy services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you do not meet the requirements to receive physical therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The file shows that 6 physical therapy visits were requested. 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 the requested therapy is not generally accepted as specific and effective therapy beyond what was already approved by the Plan. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist.
You have been instructed in safety and a home exercise program. The requested services are not part of a maintenance program. The specialized skill of a qualified therapist required to establish, design, or deliver a program to maintain your current condition or to prevent/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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve physical therapy services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for transvaginal ultrasound (76830), pelvic ultrasound (76856) and vascular study (93975) provided on June 14, 2021.

You asked the Plan to pay for the transvaginal ultrasound, pelvic ultrasound and vascular study. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service 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 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 transvaginal ultrasound, pelvic ultrasound and vascular study. Our reviewer says that CPT codes 76830, 76856 and 93975 do not meet criteria for billing or reimbursement consideration. Our reviewer found for CPT code 76856, a complete pelvic ultrasound to include: uterus, adnexal structures, ovaries, endometrium, bladder are documented in the report. Therefore, this procedure cannot be confirmed as performed. For CPT 76830, documentation does not include enough detail to support that the transvaginal ultrasound was a separate procedure, as there are two of the exact same report. For CPT 93975, documentation does not include a duplex scan of arterial inflow and venous outflow, and therefore cannot be confirmed as performed.

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 transvaginal ultrasound, pelvic ultrasound and vascular study have not been met. Therefore, we decided that the Plan does not have to pay for transvaginal ultrasound (76830), pelvic ultrasound (76856) and vascular study (93975) provided on June 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that the enrollee's brain bleed set him back months. The Plan denied your request. The Plan says the approved visits can finalize training on the home exercise program.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. The file shows that 7 physical therapy visits were requested. The Plan has agreed to pre-approve 5 visits. 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 additional services.
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 Plan. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, or under the supervision of a therapist. He has been instructed in and is compliant in a home exercise program. The specialized skill, knowledge and judgment of a qualified therapist are not required to establish, design, or deliver a program to maintain his 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hole the enrollee harmless for cardiology services provided to the enrollee from
October 27, 2020, to April 26, 2021, minus any applicable copayment.
You asked the Plan to pay for these services (minus any applicable copayment). You say that these services
should be covered for the enrollee. The Plan denied your request. The Plan says that the Plan provider needs to
submit a corrected claim.
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. The enrollee has no control over claim disputes between the Plan and contract
providers. In addition, if it is not the Plans intention for the enrollee to pay for these services, they did not make
that clear in the case file. Therefore, we decided that the Plan must hold the enrollee harmless for cardiology
services provided to the enrollee from October 27, 2020, to April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the examination and selection of retrieved archival services coded 88363 provided on June 11, 2020.
You asked the Plan to pay for the examination and selection of retrieved archival services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 88363 is examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, KRAS mutational analysis).
We find that CPT code 88363 is not supported in the medical record. Specifically, this code has a professional component/technical component indicator of 0. Modifiers 26 and technical component cannot be used with these codes. Review of the file shows that this code was billed with modifier 26. This means this code was billed with an invalid modifier. Based on this information, we decided that Medicare rules for coverage of the examination and selection of retrieved archival services have not been met. Therefore, we decided that the Plan does not have to pay for the examination and selection of retrieved archival services coded 88363 provided on June 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-network physical therapy.

You asked the Plan to pre-approve out-of-network physical therapy. You say that you have been approved
before and the member needs to continue treatment. The Plan denied your request. The Plan says in-network
providers are available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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
out-of-network physical therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional transportation trips (A0110).

You asked the Plan to pre-approve additional transportation trips. You say that you need additional trips to get to appointments. The Plan denied your request. The Plan says additional trips in excess of 20 one-way trips are not covered by the Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 20 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional transportation trips (A0110).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance (CPT code 64484) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee may have up to two (2) injections at one (1) level or one injection at two different levels on the same day. The enrollee's doctor has requested more than two injections on a single day. For this reason, this injection is not medically necessary for the enrollee at this time. Therefore, we decided that the Plan does not have to pre-approve injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance (CPT code 64484) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endodontic therapy of a molar tooth (D3330), treatment of root canal obstruction (D3331), incomplete endodontic therapy (D3332), and a first intraoral periapical x-ray (D0220).
You asked the Plan to pre-approve the endodontic therapy of a molar tooth, treatment of root canal obstruction, incomplete endodontic therapy, and first intraoral periapical x-ray. You say that the enrollee is currently in pain and would like to proceed with the treatment plan. The Plan denied your request. The Plan says the endodontic therapy of a molar tooth, treatment of root canal obstruction, and incomplete endodontic therapy are not covered services. The Plan also says that the first intraoral periapical x-ray exceeds the benefit allowance.
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, endodontic therapy of a molar tooth (D3330), treatment of root canal obstruction (D3331), and incomplete endodontic therapy (D3332) are not among those covered under this benefit. The contract says that first intraoral periapical x-ray (D0220) is limited to once every calendar year. The record shows that the enrollee received a first intraoral periapical x-ray (D0220) on August 9, 2021, and the enrollee's first intraoral periapical x-ray (D0220) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve an endodontic therapy of a molar tooth (D3330), treatment of root canal obstruction (D3331), incomplete endodontic therapy (D3332), and a first intraoral periapical x-ray (D0220).
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 IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you have a past medical history of stroke with residual right sided weakness in
2015, atrial fibrillation, hypertension, chronic obstructive pulmonary disease and depression and is living in an assisted living facility with functional decline. 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical laparoscopy.
You asked the Plan to pre-approve the surgical laparoscopy. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees who have: (1) a body mass index (BMI) of greater than or equal to 35; (2) at least one co-morbidity related to obesity; and (3) been unsuccessful with medical treatment for obesity. We looked at the file and Medicare rules. In this case, you have been reported to have a BMI that is not greater an or equal to 35. Based on this information, we decided that Medicare rules for coverage of the surgical laparoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical laparoscopy.
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. The Plan denied your request. The Plan says the enrollee does not 
require an intensive interdisciplinary approach to rehabilitation. 
 
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 physician reviewer found 
that the enrollee was admitted to the acute care hospital for congestive heart failure. His medical problems are 
stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital 
inpatient stay with an interdisciplinary approach to rehabilitation 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: 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. You say that you need help to perform daily duties. The Plan denied your request. The Plan says you do not have skilled nursing or therapy needs that need to be provided on a daily 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 from a nursing perspective, you received oral medications, had stable vital signs, and your lungs were clear. You also had had a wound vac to your right hip wound and back wounds, and dressings to your lower left extremity wound. Regarding rehabilitation services, you were at a maximal assist level for bed mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. Although there are identifiable skilled nursing service needs, you do not require skilled services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve additional services. You say that you have ongoing leg weakness. The Plan denied your request. The Plan says you do not require services of a skilled therapist.
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 additional services. 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. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, that the services can be performed only by a therapist, 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. The specialized skill of a qualified therapist is not required to establish 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a resin-based composite crown (D2390) and four pin
retentions (D2951 x4).
You asked the Plan to pre-approve the resin-based composite crown and pin retentions. You say that you need
this dental work, and the closest provider is out-of-network. The Plan denied your request. The Plan says these
services are not covered under your 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
resin-based composite crown (D2390) and four pin retentions (D2951 x4).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Foresee Home diagnostic test.
You asked the Plan to pre-approve the Foresee Home diagnostic test. You say that this service is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested diagnostic test
is considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Foresee Home diagnostic test. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found that the review indicates that the requested test is a diagnostic test that does
electronic readings from a home monitoring device to check for progression of dry age-related macular
degeneration. The enrollee's provider states that patients with dry form of Age-related Macular Degeneration
(AMD) are at high risk of developing the devastating wet form of AMD. They advised the revolutionary
development of anti-VEGF agents, patients with neovascular AMD are no longer condemned to a life of legal
blindness and loss of independence. Her provider advises that the remote diagnostic monitoring system
provided the best method for testing through a home-based remote monitoring system that can detect changes
in vision related to wet AMD, often before the patient experiences visual symptoms. The review has
determined that the requested Notal Vision's diagnostic test (known as Foresee Home) is not considered
reasonable and 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 Foresee Home diagnostic test have not been met. Therefore, we decided that
the Plan does not have to pre-approve the Foresee Home diagnostic test.