Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation and bitewing x-rays. We decided
that the Plan does not have to pay for the comprehensive oral evaluation.

You asked the Plan to pay for the comprehensive oral evaluation and bitewing x-rays. You say that you had to
see a new dentist needed who needed to take new x-rays. The Plan says that benefits for the comprehensive
oral evaluation have been satisfied and the frequency limitation has been exceeded. The Plan also says that the
bitewing x-rays are not covered.

We decided that the Plan has to pay for the bitewing x-rays.

Medicare rules say that the health plan must provide you with a clear and accurate description of the Original
Medicare and/or mandatory/optional supplemental benefits offered under your plan contract including
applicable conditions and limitations and any other conditions associated with the use or receipt of the benefits.
The record shows that you received bitewing x-rays (D0277). Bitewing x-rays are listed as a covered benefit in
the 2021 EOC. The contract does not clearly state specific bitewing x-rays that are covered under the Plan. The
documentation provided also does not show that you have exhausted your bitewings benefit. You reasonably
believed that these bitewing x-rays would be covered because bitewing x-rays are listed as a covered benefit
under the Plan.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the bitewing x-rays have been met. Therefore, we decided that the Plan has to pay for the bitewing
x-rays.

We also decided that the Plan does not have to pay for the comprehensive oral evaluation.

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, comprehensive oral evaluation
(D0150) is limited to one procedure code every three calendar years. The record shows that you received a
comprehensive oral evaluation (D0150) on August 19, 2019 and your comprehensive oral evaluation (D0150)
benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive
oral evaluation.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99349) provided on February 4, 2021 by an OON provider.

You asked the Plan to pay for the home visit. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the service was rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit (99349) provided on February 4, 2021 by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care (99223) provided on April 21, 2021.

You asked the Plan to pay for hospital care. You say that this was billed correctly. The Plan denied your request. The Plan says the enrollee was an outpatient at the time of service.

The Plan must follow Medicare rules. Medicare rules say that physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the off campus-outpatient hospital place of service (POS) code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter. 

We looked at the file and Medicare rules. The records show that the enrollee was an outpatient when the service at issue was provided, but this service was billed with an inpatient POS. Based on this information, we decided that Medicare rules for coverage of hospital care have not been met. Therefore, we decided that the Plan does not have to pay for hospital care (99223) provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the arthroplasty, glenohumeral joint; total shoulder
(glenoid and proximal humeral replacement (eg, total shoulder)) (CPT code 23472), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the service is medically necessary. The Plan
denied your request. The Plan says the enrollee's doctor did not send notes that show why this surgery is
needed. The Plan states the x-ray report and Magnetic Resonance Imaging do not support this request. The Plan
states the surgery (arthroplasty, (total shoulder replacement), with glenoid and
proximal humeral replacement (eg, total shoulder) 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 surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and
comprehensive less invasive conservative care measures for the left shoulder. In addition, the exam dated September 13, 2021, notes a request for "right" reverse total shoulder arthroplasty
and the previous exam dated August 9, 2021, had right shoulder objective findings. All imaging studies are for
the left shoulder. There is no compelling rationale presented or extenuating circumstances noted to support the
medical necessity of this request as an exception to guidelines. Therefore, the request for left reverse total
shoulder arthroplasty (23472) is not medically reasonable or 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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral
replacement (eg, total shoulder)) (CPT code 23472), for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to hold you harmless for the hospital services provided on June 9, 2021, through June 10, 2021.
You asked the Plan to hold you harmless for the hospital services. You say that you would like reconsideration because the services were medically necessary. The Plan denied your request. The Plan says that CPT code A9270 is a non-covered service.
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. You were referred for the hospital services by a contract provider. The file does not show that the Plan provided notice that the hospital services would not be covered. Under Medicare rules, this means the hospital services is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the hospital services provided on June 9, 2021, through June 10, 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 pay for the computed tomography, abdomen and pelvis provided on
February 16, 2021.

You asked the Plan to pay for the computed tomography, abdomen and pelvis, interpretation. You say that the
claim is not a duplicate. The Plan denied your request. The Plan says the claim is a duplicate.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units
provided for each procedure code.

We find that 2 units of CPT code 74177-26 are not supported in the medical record. The medical record only
supports 1 units of CPT code 74177-26. This procedure was paid for on April 6, 2021. Based on this
information, we decided that Medicare rules for coverage of the computed tomography, abdomen and pelvis,
interpretation. have not been met. Therefore, we decided that the Plan does not have to pay for the computed
tomography, abdomen and pelvis provided on February 16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from September 22, 2021,
forward.

You asked the Plan to pre-approve SNF care. You say that the enrollee is receiving physical therapy; however,
it is limited since the enrollee will not be having an x-ray done on it until September 22, 2021, and will
determine if the enrollee can put weight on it. The Plan denied your request. The Plan says the stay is not
medically necessary.

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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not meet the coverage
criteria for continued stay in an SNF. A stay in an SNF was not reasonable and not medically necessary for a
patient who has Dementia and poor carryover with poor functional progress after six (6) weeks of SNF
therapies. The enrollee was stable medically with poor functional progress since the beginning of therapies. Did
not need any nursing care other than routine care. The enrollee has no skilled nursing needs such as intravenous
(IV) medications or skin care. The enrollee's mobility and activity of daily living (ADL) needs can be
addressed by unskilled attendants. Documentation does not support the need for continued stay in an SNF with
daily skilled therapies in an inpatient setting. The enrollee's care needs can be safely provided at an alternate
and lower intensity setting such as in an long-term care (LTC) facility.

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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continuation of SNF care from September 22, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472).

You asked the Plan to pre-approve a total shoulder arthroplasty. You say that the enrollee's symptoms will worsen without surgery. 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 total shoulder arthroplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not document a trial and failure of recent, reasonable, and comprehensive conservative care measures. In addition, there are no imaging studies provided to support the diagnosis. 

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 total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a total shoulder arthroplasty (23472).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on February 1, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were provided in good faith. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the provider must document the patient's medical record the date of consultation with the physician or, if attempts to consult did not succeed, the date and manner of notification to the physician. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided medical records do not document a consultation with or notification of the enrollee's primary care or attending physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure machine (CPAP).

You asked the Plan to pre-approve the CPAP. You say that the CPAP is dangerous to use and there is no estimate that the provider will give a new one. The Plan denied your request. The Plan says that the request is not approved because equipment is already available to the beneficiary.

The Plan must follow Medicare rules. Medicare rules say that item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). There has been a class I FDA recall on the device, which is the most serious. It has an estimated 12 month repair and replacement program. 12 months is unacceptable repair time frame on a tool needed for the enrollee to breathe. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CPAP have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure machine (CPAP).

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: 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. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There is no discussion of scoliosis of the lumbar spine/documentation of applicable Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this patient. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-5 levels is not medically reasonable or 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 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 26, 2021.

You asked the Plan to pay for psychotherapy services. You say that the medically necessary services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's physician and document in the patient's medical record the date of consultation or, if attempts to consult did not succeed, the date and manner of notification to the physician. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided medical records do not document a consultation with or notification of the enrollee's primary care or attending physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on February 26, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit (99350), smoking and tobacco use cessation counseling visit (99406), and advance care planning (99497) provided on April 26, 2021 by an OON provider.
You asked the Plan to pay for the home visit, smoking and tobacco use cessation counseling visit, and advance care planning. You say that you do not agree with the Plan's decision and would like these services to be reconsidered for payment. The Plan denied your request. The Plan says these services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained. 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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the home visit (99350), smoking and tobacco use cessation counseling visit (99406), and advance care planning (99497) provided on April 26, 2021 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal surgery (22612).

You asked the Plan to pre-approve the spinal procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 spinal procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding dynamic flexion/extension films to potentially assess the amount of movement (instability) at the requested surgical level. Nonunion of prior fusion is not evident. Detailed documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request.

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 spinal procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery (22612).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and
the unspecified preventative procedure, by report (D1999) provided April 21, 2021.

You asked the Plan to pay for the limited oral exam and unspecified preventative procedure (PPE). You say
that you only wanted bitewing x-rays and don't believe you should be responsible for the cost of the remaining
services. The Plan denied your request. The Plan says the limited oral exam and unspecified preventative
procedure (PPE) are not covered under your benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
limited oral evaluation - problem focused (D0140) and the unspecified preventative procedure, by report
(D1999) provided April 21, 2021.