Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the guidelines for coverage have been met. You say that if the enrollee is not approved for this device her health will start to deteriorate. The Plan denied your request. The Plan says the severity of the enrollee's chronic obstructive pulmonary disease (COPD) is not documented by pulmonary function testing. The Plan says that there is no evidence of chronic respiratory failure, given the lack of arterial blood gases (ABG) results provided. The Plan says that there is no evidence that the enrollee attempted to utilize a bilevel positive airway pressure (BiPAP).
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 portable ventilator. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is considered not medically necessary in this case. This enrollee has chronic obstructive pulmonary disease (COPD), but there is no documentation of carbon dioxide retention. There has been a suspicion of obstructive sleep apnea, and this has not been excluded. Bilevel positive airway pressure (BiPAP) has not been tried, and there is no documented failure of BiPAP or continuous positive airway pressure (CPAP) in the home setting. Medicare does not cover a home ventilator when used as BiPAP. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 CGM.

You asked the Plan to pre-approve the FreeStyle Libre 2 CGM. You say that you feel the CGM is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee must use insulin injections three or more times per day or use a Medicare-covered insulin pump.

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 indicates that the enrollee does not use insulin with at least three daily injections. The record shows that the Plan has confirmed with the provider's office that the enrollee is using insulin only once per day. Additionally, the provider did not submit medical records showing that the enrollee uses insulin three times or more per day. Based on this information, we decided that Medicare rules for coverage of the FreeStyle Libre 2 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 CGM.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

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 you are a 77-year-old female with a history of hypertension, chronic obstructive pulmonary disease, and obesity. On September 18, 2021, you were admitted to an acute care hospital after a fall. Based on the limited documentation provided, you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on May 20, 2021.
You asked the Plan to waive the copayment for laboratory services. You say that you should owe $0 for laboratory services. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $40 copayment for laboratory services provided in an physician's office and a $40 copayment when provided at an outpatient hospital facility. You received laboratory services at an outpatient hospital facility on May 20, 2021. Therefore, you are responsible to pay the $40 copayment.
You have been asked to pay a $40 copayment for laboratory services. Laboratory services fall within the laboratory services benefit category. 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 laboratory services provided on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.

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 services are not medically necessary. Our physician reviewer found bone marrow aspirate remains
experimental i nature for use as a bone graft. More research is needed to show its safety and efficacy. 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 bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88172 and 88173) provided to the enrollee on March 1, 2021.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. For CPT code 88172: National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 88104 and 88172. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. For CPT code 88173: National Correct Coding Initiatives (NCCI)

Procedure to Procedure (PTP) edit exists between 88104 and 88173. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 88172 and 88173) provided to the enrollee on March 1, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous repair with a tricuspid valve clip (TriClip).

You asked the Plan to pre-approve percutaneous repair with a tricuspid valve clip (TriClip). You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that medical studies have not proven that the service or procedure is helpful for treatment of tricuspid regurgitation.

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 percutaneous repair with a tricuspid valve clip (TriClip). Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the patient has severely symptomatic tricuspid insufficiency despite maximally tolerated therapy with diuretics. The transesophageal echocardiography and cardiac catheterization do not suggest any other causes of the symptoms including significant pulmonary hypertension, systemic hypertension, congestive heart failure or coronary artery disease. She has been assessed by the heart team and felt to be at higher risk for open repair and has been referred for percutaneous repair with a tricuspid valve clip (TriClip) as part of a Medicare-approved Investigational Device Exemption (IDE) study of the device. Isolated tricuspid insufficiency is difficult to treat with medical therapy and she has already failed maximal treatment. Surgical repair has been another option in the past, but this carries with it significant morbidity and mortality risk in selected patients. Although still investigational, there is provided documentation that the patient is participating in a Medicare-approved IDE study of this tricuspid clip device making the procedure eligible for Medicare reimbursement. In addition, this would also meet the criteria of medical necessity and reasonableness based on the current 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 percutaneous repair with a tricuspid valve clip (TriClip) have been met. Therefore, we decided that the Plan has to pre-approve percutaneous repair with a tricuspid valve clip (TriClip).

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 pre-approve repeat radiofrequency ablation (RFA).

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 repeat RFA is covered when specific criteria are met. 

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 services are not medically necessary. Our physician reviewer found the records show that you have chronic low back pain and sacroilitis. You underwent RFA on March 22, 2021 that produced 80 percent pain relief initially and 50 percent for six weeks. Repeat RFA requires at least six months of 50 percent pain relief. That was not achieved; therefore, repeat RFA is not 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 repeat radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).

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. The rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

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 services are not medically necessary. Our physician reviewer found you have low back pain and had RFA of both sides in December of 2020 with minimal relief. You then had left RFA with good result. The request is now for right RFA, which would be the third treatment. The request exceeds the limits in the Medicare criteria. 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 repeat radiofrequency ablation (RFA).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test (CPT code G0482) provided to the enrollee on November 25, 2020.

You asked the Plan to pay for the drug test. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. You respectfully request that the Plan does not penalize the laboratory for being out- of-network as you continue to do your part in providing timely testing and results to the Coronavirus pandemic. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. CPT code G0482 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on November 25, 2020 and received by the lab on December 1, 2020. Of note, the patient resides in Alabama (AL) and the billing laboratory is located in Georgia (GA); therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug test (CPT code G0482) provided to the enrollee on November 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placement (D6010),
radiographic/surgical implant index (D6190), osseous, osteoperiosteal, or cartilage graft (D7950) and
intravenous moderate sedation (D9239 and D9243).

You asked the Plan to pre-approve the surgical implant placement (D6010), radiographic/surgical implant
index (D6190), osseous, osteoperiosteal, or cartilage graft (D7950) and intravenous moderate sedation
(D9239). The Plan denied your request. The Plan says the Plan approved $1,000 toward the cone beam CT scan
and collection and application of autologous blood concentrate product. The Plan also says the remaining
services are not covered 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 pre-approve the
surgical implant placement (D6010), radiographic/surgical implant index (D6190), osseous, osteoperiosteal, or
cartilage graft (D7950) and intravenous moderate sedation (D9239 and D9243).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular
partial denture (D5214).

You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that
the enrollee will be unable to properly function and masticate food without teeth to replace those that are
missing. 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. Dentures are only covered under the comprehensive dental benefit, and
the record shows that the enrollee did not sign up for this benefit. Therefore, we decided that the Plan does not
have to pre-approve a maxillary partial denture (D5213) and mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313).

You asked the Plan to pre-approve an expandable controller. You say that these requested items are medically necessary and reasonable. The Plan denied your request. The Plan says an expandable controller is not medically necessary and reasonable.

The Plan follows Medicare rules. Medicare rules say that an expandable controller is subject to the criteria listed 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 an expandable controller. Our reviewer says that the requested items are not medically reasonable and necessary. Our physician reviewer found The documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and function in the right upper extremity supports that the patient can control any power options through their own individual switches. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #19.

You asked the Plan to pre-approve the crown. You say that this service is necessary and should be covered. The Plan denied your request. The Plan says the requested crown is not medically necessary, as there is no evidence of significant breakdown on this tooth.

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. The Plan covers the crown when the services are medically necessary and reasonable. 

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 crown. Our reviewer says that the health Plan's denial of the requested crown appears appropriate in this case. Our physician reviewer found based on the enrollee's dental record and provided radiographs, there does not appear to be significant coronal breakdown of tooth #19 due to caries or fracture to warrant a crown restoration. The documentation provided does not provide evidence that the criteria for coverage of a crown restoration is indicated or medically necessary for the requested tooth.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D2740) for tooth #19.