Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740) provided July 7, 2021.
You asked the Plan to pay for the crown. You say that the services were medically necessary. The Plan denied your request. The Plan says this is not a covered service.
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 crown (D2740) provided July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperparathyroidism risk assessment panel testing provided on December 5, 2020.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because screening testing is not a Medicare-covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hyperparathyroidism risk assessment panel testing provided on December 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.

You asked the Plan to pre-approve transurethral waterjet ablation of prostate. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that treatment for lower urinary tract symptoms/benign prostatic hyperplasia (LUTS/BPH) treatment will be considered reasonable and necessary under specific circumstances.

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 transurethral waterjet ablation of prostate. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not meet criteria as the enrollee has not had an adequate flow study with a voided volume greater than 125 cc and has not had a prostate volume study with transrectal ultrasound of the prostate (TRUSP). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transurethral waterjet ablation of prostate have not been met. Therefore, we decided that the Plan does not have to pre-approve transurethral waterjet ablation of prostate.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation provided on July 23, 2020.
You asked the Plan to pay for the gingival irrigation. You say that all your dental work up to this has been paid for and you don't know why $140 was not paid. You say that you are on a fixed income and need this resolved. The Plan denied your request. The Plan says the extraction and unspecified preventive procedure were approved, and the gingival irrigation remains denied as a non-covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation provided on July 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the drug is not being prescribed for a medically-accepted
indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Keytruda. Our reviewer says that
Keytruda is not medically reasonable and necessary for the enrollee in this case. Keytruda is not FDA-approved
for the enrollee's diagnosis. The use of Keytrua is not supported by one of the major drug compendia or by
clinical research that appears in a Centers for Medicare and Medicaid Services-approved medical journal. Our
physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with lead acid battery.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee has a mobility deficit but it is not clear from the documentation that it impairs the completion of mobility-related activities of daily living (MRADLs) in the home or that it cannot be helped by a walker, cane, or manual wheelchair. While the enrollee may have the cognitive capacity to safely operate the PWC, the records do not support that the criteria for coverage are met. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC) with lead acid battery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says
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 the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard mattress for the enrollee.

You asked the Plan to pre-approve a standard mattress. You say that this is necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

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 a standard mattress for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided
on March 8, 2021.
You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that
the Plan should pay this claim. The Plan denied your request. The Plan says Medicare does not pay for
preventative services and payment would have been included in the facility claim.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0675) is a preventive service.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliances
provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the prostate cancer screening; prostate specific antigen test
(PSA) provided April 8, 2021.
You asked the Plan to pay for the prostate cancer screening (PSA) test. You say that the enrollee's doctor feels
it is necessary to have the PSA done so he knows how the enrollee is doing. The Plan denied your request. The
Plan says you have exceeded the frequency limit for this service.
The Plan follows Medicare rules. The Plan covers the PSA screening test once every 12 months.
We looked at the file and Medicare rules. The Plan provided documentation showing that a PSA screening test
was previously covered on February 11, 2021. Based on this information we decided that the Plan's frequency
limit for PSA screening tests has been exceeded. Therefore, we decided that the Plan does not have to pay for
the prostate cancer screening; prostate specific antigen test (PSA) provided April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device (PMD).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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. 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 criteria for coverage are not met. Our physician reviewer found the records show that you have a mobility deficit but it does not impair the completion of mobility-related activities of daily living (MRADLs) in the home. The records do not support that the mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair. The progress note dated August 19, 2021 states you have good upper body strength. The requested PMD exceeds your medical needs and is not reasonable or medically necessary at this time.
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 a power mobility device (PMD).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit provided on May 1, 2021.
You asked the Plan to pay for the emergency department visit (99284). You say that you do not have any other insurance. The Plan denied your request. The Plan says that the Explanation of Benefit was not received timely from the primary insurer.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has not met its obligation with regards to coordination of benefits. Specifically, the Plan has not sent the bill to the primary insurer, directed the provider to send the bill to the primary insurer or paid the bill and submitted it for reimbursement to the primary insurer. Therefore, we decided that the Plan has to pay for the emergency department visit provided on May 1, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the medical records do not suggest that this request has been recommended by the treating physician.
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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the records do not show 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 records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. As the enrollee is not receiving skilled nursing or skilled therapy, the criteria for a home health aide is not met, and the request is not reasonable and necessary for the treatment of the enrollee's illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided on June 2, 2021, to June 4, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says that criteria for acute inpatient admission had not been met.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided on June 2, 2021, to June 4, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (99830) provided to the enrollee on
March 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says this code represents an unbundled service.
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 99830 is "Supervision of a nursing facility patient
(patient not present) requiring complex and multidisciplinary care modalities involving regular development
and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related
laboratory and other studies, communication (including telephone calls) for purposes of assessment or care
decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian)
and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment
plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more.
We find that CPT code 99830 is not supported in the medical record. Specifically, this code has a status
indicator of "B" which means that it cannot be paid separately. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for skilled nursing facility (99830) provided to the enrollee on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure, on one or more areas, each lasting 15 minutes provided December 4, 2019.
You asked the Plan to pay for the therapeutic services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this code is not appropriate for 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.
In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records indicates that the service is performed by a physical therapist assistant in a home health or hospice setting. There is a more appropriate healthcare common procedure coding system (HCPCS) code (G0157) for the service billed. The plan made multiple attempts to obtain additional inform from the provider without success. Based on this information, we decided that Medicare rules for coverage of the therapeutic services have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure, on one or more areas, each lasting 15 minutes provided December 4, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Cxbladder test provided on April 9, 2021.
You asked the Plan to pay for the Cxbladder Detect test. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did submit records showing that the referring provider is out-of-network. This means we cannot determine if the Plan's denial of the out-of-network services is supported. Therefore, we decided that the Plan has to pay for the Cxbladder test provided on April 9, 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.