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

We decided that the Plan does not have to waive the deductible for the removal of cataract with insertion of prosthetic lens (66984) provided on February 22, 2021, by an in-network provider.
You asked the Plan to waive the deductible for cataract surgery. You say that you cannot afford this bill and would have turned down the surgery if you knew you would be charged this amount. You do not think you should be responsible because the surgery did not help you. The Plan denied your request. The Plan says the claim was processed correctly. Your annual deductible had not been met at the time of service.
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 an $800 deductible which applies to Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The surgery you asked the Plan to waive the deductible for falls within the benefit category Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an $800 deductible which applies to outpatient surgery.
This cost-sharing is a contractual obligation that had not been met at the time cataract surgery was received on
February 22, 2021. You are responsible for the full cost of your covered services until the deductible is met, at
which point, the Plan will begin paying their share. Therefore, we decided that the Plan does not have to waive
the deductible for the removal of cataract with insertion of prosthetic lens (66984) provided on February 22,
2021, by an in-network provider.
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 cannot ambulate and are at high risk for falling. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.
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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional skilled nursing visits (CPT code G0299 X 4), for the enrollee.
You asked the Plan to pre-approve the skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's records do not support the need for a skilled nurse to make more visits.
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 skilled nursing visits. Our physician reviewer found based on the medical records provided there is no documentation that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The provided records do not document an acute change in status or medication change or other skilled nursing need. Records do not document why the previously approved skilled nursing visits have been inadequate to address the enrollee's health needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional skilled nursing visits (CPT code G0299 X 4), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heart ultrasound to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the heart ultrasound. You say that the service is medically necessary. 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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the heart ultrasound to be provided by an out-of-network (OON) provider
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing (G0483) provided on May 20, 2021.
You asked the Plan to pay for drug testing. You say that you are appealing with records to prove the necessity of this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the documentation submitted shows test results for only 15 drug classes.
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 G0483 is drug test(s), definitive; qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolites if performed. We find that CPT code G0483 is supported in the medical record. Specifically, the record includes definitive test results for more than 22 drug classes. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on May 20, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says this is not covered by the Plan or Medicare.
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 test at issue in this appeal, the CT scan, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pre-
approve CT, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0427, A0425) provided on October 9, 2020.
You asked the Plan to waive the copayment for the ambulance transportation. You say that this cost is too expensive and difficult for you to pay. The Plan denied your request. The Plan says ambulance services require a $275 copayment. This claim was 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 $275 copayment for each Medicare-covered one-way ambulance trip. You have been asked to pay a $275 copayment for the ambulance transportation. 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 copayment for the emergency ambulance transportation services (A0427, A0425) provided on October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240) and a grab bar (E0243).
You asked the Plan to pre-approve a shower chair and a grab bar. You say that you need these items for your safety. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. Grab bars are not covered because they are considered self-help items that are not primarily medical in nature. While a shower chair and a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Based on this information, we decided that Medicare rules for coverage of a shower chair and a grab bar have not been met. Therefore, we decided that the Plan does not have to pre-approve a shower chair (E0240) and a grab bar (E0243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration), tooth #11 (CPT code D3310).
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is not a covered benefit under the 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. This service is not listed in your handbook as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy, anterior tooth (excluding final restoration), tooth #11 (CPT code D3310).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee is a good candidate for these services and would not be a candidate for more invasive surgery. 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 vertilfex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 the Vertiflex Superion device for the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955) provided on March 12, 2021.
You asked the Plan to pay for the EEG during surgery. You say that these services were medically necessary and reasonable. The Plan denied your request. The Plan says they agree that the continuous intraoperative neurophysiology monitoring and neuromuscular junction testing are medically necessary, and they will pay for these services. However, the EEG is not medically necessary in this case.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the EEG during surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Current Procedural Terminology (CPT) code billed has otherwise been used inappropriately. A two channel EEG falls significantly below the American Clinical Neurophysiology Society (ACNS) established technical standards for performance of EEG. There is not a defined utility from using intraoperative EEG during lumbar spine surgery. The EEG does not provide any clinical benefit or utility in the evaluation of an enrollee. Therefore, this code would not be 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 EEG during surgery have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (EEG) during non-intracranial surgery (95955) provided on March 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a single crown restoration (D6058), and a custom fabricated abutement (D6057).
You asked the Plan to pay for a single crown restoration and a custom fabricated abutement. You say that the services should be covered. The Plan denied your request. The Plan says you have exhausted the Plan's maximum 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, 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 a single crown restoration (D6058), and a custom fabricated abutement (D6057).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the
blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued partial hospitalization care on a weekly basis.
You asked the Plan to pre-approve partial hospitalization services. You say that the partial hospitalization services are medically necessary and beneficial to the enrollee. The Plan denied your request. The Plan says
continued partial hospitalization services are not medically necessary, and the enrollee may be appropriate for an alternate level of care.
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 partial hospitalization services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee began a partial hospitalization program from July 1, 2021, with a diagnosis of Bipolar Disorder, Current Episode Depressed, Severe with Psychotic Features. Based on review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as she was not showing impairment of reality, suicidal or homicidal thoughts. It did not appear medically necessary and reasonable to have psychiatric care provided at the partial hospitalization level of care rather than a lower level of care beyond the dates in question as she did not show any difficulties with command hallucinations and paranoia. The health plan's denial of continued partial hospitalization treatment for the dates in question appears appropriate. Based upon a review of the records provided, it does not appear that this enrollee required partial hospitalization treatment beyond the date in question of October 12, 2021, forward and could have been treated in a lesser restrictive setting as she was not showing any psychiatric instability including suicidal or homicidal ideation, and was not showing any psychosis or aggressive behaviors but was also not showing any medical instability or need for this intensity of 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 partial hospitalization services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued partial hospitalization care on a weekly basis.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crutch substitute, lower leg platform, with or without wheels, each (CPT code E0118), for the enrollee.
You asked the Plan to pre-approve the crutch substitute. You say that the enrollee developed multiple pressure ulcers on the plantar aspect of the enrollee's foot. You state at this point it appears that the bone is not infected, and you are optimistic that it will heal with off-loading pressure, wound care, and antibiotics. You state a knee scooter would benefit for the enrollee. The Plan denied your request. The Plan says a knee walker to assist the enrollee with their foot pain is a convenience item and it is not medically necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The knee walker is not a standard walker. The knee walker is a convenience item as a lesser device can address mobility deficits. The records do not indicate a contraindication to standard wheelchair/walker use. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the
Plan does not have to pre-approve crutch substitute, lower leg platform, with or without wheels, each (CPT
code E0118), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve a power wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the requested item.
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 shows that your condition can be improved by a walker, cane or manual wheelchair. While the documentation shows that you have problems pushing your manual wheelchair due to your arthritic hands, a home evaluation for the requested power wheelchair has not been performed. This home evaluation is required to determine whether you would be able to safely operate 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 a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that the enrollee has dementia and becomes combative
when testing blood sugar. The Plan denied your request. The Plan says the criteria is not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and 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 assesses
adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor