Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sign language or oral interpretive services coded T1013
provided on February 22, 2021.
You asked the Plan to pay for the sign language or oral interpretive services. You say that you would like the
plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not
payable.
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 T1013 is sign language or oral interpretive services, per
15 minutes. We find that CPT code T1013 is not supported in the medical record. Specifically, this code has a status code
of "I." A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code
for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the sign language or oral interpretive services have not been met. Therefore, we decided that the
Plan does not have to pay for the sign language or oral interpretive services coded T1013 provided on February
22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on January 9, 2021.
You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable 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. In this case, we have confirmed that code 71045
for the x-ray services has a bundled relationship with code 71101 and cannot be paid as billed. This code
cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been
met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on
January 9, 2021.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the complete upper denture (D5110).
You asked the Plan to pre-approve the complete upper denture (D5110). You say that your gums shrank, and your denture is way too big. You say that the dentist cannot make them fit and the decision should be considered. The Plan denied your request. The Plan says the service is only allowed once every 60 months.
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, you also have a maximum benefit of one of D5110, D5130, D5211 or D5213 per 60 months. The Plan paid for the immediate upper denture (D5130) provided on January 22, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pre-approve the complete upper denture (D5110).
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 medical studies have not proven that this device is helpful for treatment of the health
problem.

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 current evidence based medical guideline and peer reviewed literature do not fully support the spinal
decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large
volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical
condition as discussed above. FDA indications include implantation of the Superion device at one or two
adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no
more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA
indicated levels of "moderate" spinal stenosis (including the planned level of implantation L3-4 level.)

FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been
adequately addressed in the medical records. There is imaging evidence of grade 1 retrolisthesis at L5-S1 with
no discussion of spinal instability on flexion/extension films. There is no discussion of scoliosis or
documentation of applicable Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated
the lack of significant osteoporosis in this 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 14, 2021.
You asked the Plan to pay for the x-ray 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 separately payable. 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, we have confirmed that code the x-ray services has a bundled relationship with code 71045 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71045 provided on April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right shoulder replacement (23472).

You asked the Plan to pre-approve a right shoulder replacement. You say that this is the best course of action based on the enrollee's condition. 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 a right shoulder replacement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show that the enrollee has had a recent trial of physical therapy 

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 right shoulder replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve a right shoulder replacement (23472).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital or ambulatory surgical center call (D9420).

You asked the Plan to pre-approve the hospital or ambulatory surgical center call. You say that because of the enrollee's disabilities, he needs anesthesia in order to receive any type of dental exam or treatment if necessary. 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 hospital or ambulatory surgical center call (D9420).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve coronary artery catheter placement (93458).
You asked the Plan to pre-approve coronary artery catheter placement. You say that delaying this procedure is detrimental to your health. The Plan denied your request. The Plan says that the requested procedure is not indicated at this time.
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 coronary artery catheter placement. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the records show that you have complaints of dyspnea and have had a Lexiscan stress test that was positive for ischemia in two cardiac territories. Diagnosis of possible obstructive coronary artery disease by cardiac catheterization is both reasonable and backed by medical guidelines in this clinical situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of coronary artery catheter placement have been met. Therefore, we decided that the Plan has to pre-approve coronary artery catheter placement (93458).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve diabetic supplies from a non-preferred provider.

You asked the Plan to pre-approve the requested services. You say that the enrollee has been using these supplies to safely control his blood sugar. The Plan denied your request. The Plan says the preferred products work with the enrollee's current meter.

The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred.

The requested brand in this case is not a preferred brand with the Plan. The Plan has preferred products available for the services at issue in this appeal. We found no exception that would require the Plan to pre-approve the requested items. Therefore, we decided that the Plan does not have to pre-approve diabetic supplies from a non-preferred provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion Interspinous device 
(22869, 22870). 
 
You asked the Plan to pre-approve the insertion of a Vertiflex Superion Interspinous device. You say that this 
is medically necessary. The Plan denied your request. The Plan says this is experimental. 
 
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 insertion of a Vertiflex Superion 
Interspinous device. Our reviewer says that the requested services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is 
needed to show that it is safe and effective. 
 
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 insertion of a Vertiflex Superion Interspinous device have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex Superion 
Interspinous device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 14, 2021.
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says this service was not an emergency, urgently needed care, or out-of-area dialysis, and an authorization was not obtained prior to services rendered from this out-of-network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 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 subsequent nursing facility care provided on May 14, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G6 receiver transmitters and sensors.

You asked the Plan to pre-approve Dexcom G6 receiver transmitters and sensors. You say that you would like
the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet
criteria for the requested items.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs and related supplies 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. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 receiver transmitters and sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 receiver transmitters and sensors.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 13, 16, 18, and 20, and pontics (D6241) for teeth # 14, 15, 19, and 30.
You asked the Plan to pre-approve the dental services. You say that the requested dental services are medically necessary. The Plan denied your request. The Plan says retainer crowns are not listed as covered services. The Plan says that pontics are not listed as covered services 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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve retainer crowns (D6751) for teeth # 13, 16, 18, and 20, and pontics (D6241) for teeth # 14, 15, 19, and 30.
Appeal type: Practitioner Services
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 requested device. The Plan denied your request. The Plan says the enrollee does not meet the guidelines.

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. The documentation does not indicate that the enrollee performs blood
glucose testing at least four times per day, uses 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 requested device have not been met. Therefore, we decided that
the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation services coded 99254 provided on February 2, 2021.
You asked the Plan to pay for the inpatient consultation 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 payable.
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 99254 is inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate 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 moderate to high severity. Typically, 80 minutes are spent at the bedside and on the patient's hospital floor or unit. We find that CPT code 99254 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that these services are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the inpatient consultation services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient consultation services coded 99254 provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided from March 4, 2021, through March 5, 2021.

You asked the Plan to pay for outpatient hospital services. You say that the claim denied for not paid separately when patient is an inpatient, but the denial is incorrect. You say that the claim should be reprocessed as outpatient hospital admission through discharge. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.

The Plan must follow Medicare rules. Medicare rules say that CMS does not pay for an "inpatient-only" service furnished to a person who is registered in the hospital as an outpatient and reports the service on the outpatient hospital bill type.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient hospital services have not been met. Specifically, this claim was billed on an outpatient hospital bill type, Type of Bill 131, with CPT code 19361. Per the Outpatient Hospital Prospective Payment System, CPT code 19361 is considered inpatient only. CMS does not pay for inpatient only services or any other services rendered on the same day as the inpatient only procedure when billed on an outpatient hospital bill type. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided from March 4, 2021, through March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2740), core buildup, including any pins when required (D2950), endodontic therapy (D3320), and two extractions (D7140 x2).

You asked the Plan to pre-approve the crown, core buildup, endodontic therapy, and extractions. The Plan denied your request. The Plan says these services are 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 crown (D2740), core buildup, including any pins when required (D2950), endodontic therapy (D3320), and two extractions (D7140 x2).