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

 We decided that the Plan does not have to pre-approve an Intracept procedure.  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 the requested Intracept procedure is considered experimental in nature, as more research is needed to support 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 an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021. 

 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 are not covered.  

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, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient mental health services provided from May 11, 2021, to June 9, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for inpatient mental health services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the claim was denied for no authorization received, and the member utilized a non-contracted 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 had network providers available who could have provided the items/services at issue in this appeal. 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 inpatient mental health services provided from May 11, 2021, to June 9, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pneumatic compression device coded as (E0651) and appliances (E0667 x2).  You asked the Plan to pre-approve intermittent limb compression device and appliance. You say that you are appealing to be able to purchase an edema pump. You have constant swelling in your legs due to fluid buildup in your legs. The Plan denied your request. The Plan says the Medicare criteria has not been met as there has not been a4 week trial of conservative treatment including compression and manual drainage.  The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.  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 intermittent limb compression device and appliance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provider prescribed both compression and the lymphedema pump without any plan for follow-up. As there has not yet been demonstration of failure to respond to the compression regimen prescribed, this criterion has not been met. There are numerous compression regimens available that do not require the shoulder strength needed to don standard stockings. These options include, but are not limited to, Velcro style compression garments. Generally, lymphedema pumps are prescribed in conjunction with an overall plan for lymphedema care with ongoing follow-up.  As there has been no clear lymphedema treatment plan and no demonstration of failure to respond to conservative treatments, coverage criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device and appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device coded as (E0651) and appliances (E0667 x2).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve the SNF admission. You say that you want to stay at the SNF you are staying at currently. The other facility is not your preference because thy provide less medical care. The Plan denied your request. The Plan says medical necessity cannot be established for SNF level of coverage.

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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. The enrollee does have skilled therapy service needs but does not require skilled therapy on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (22514).  You asked the Plan to pre-approve the percutaneous vertebral augmentation (22514). You say that the patient is not able to sleep through the night due to pain and the pain increases with standing, bending, and twisting. You say that the MRI reveals compression fractures that are the cause of the pain, and the service should be approved. The Plan denied your request. The Plan says the request is not a covered benefit because the records do not show new acute or subacute vertebral compression fractures.  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 percutaneous vertebral augmentation (22514). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the LCD restricts vertebroplasty to acute or subacute fractures which this patient does not have.   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 percutaneous vertebral augmentation (22514) have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation (22514).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).  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 criteria for coverage are not met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you do not treat with insulin three or more times per day or use an insulin pump. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on July 12, 2021.

You asked the Plan to pay for the services provided. You say that the documents justify billing. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

In this case, the CPT Code Manual definition of code 63057 is Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure). We find that code 63057 was an incidental service to the primary procedure and not separately billable.

The file shows that CPT codes 63056, 63012, and 76000 were billed with a -59 modifier. The medical records provided do not show that the services billed with the -59 modifier were distinct procedural services. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the surgery services provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital services provided on November 9, 2020, by an out-of-network provider.  You asked the Plan to pay for hospital services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.  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 had network providers available who could have provided the items/services at issue in this appeal. 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 hospital services provided on November 9, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you are no longer a danger to self or others.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   Continued inpatient care from February 24, 2022, forward, was requested.  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 continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment from February 24, 2022, forward. You could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations. You were not showing any aggressive behaviors while being cooperative and compliant.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from May 23, 2021, to May 29, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the inpatient care was not medically necessary.  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 provided documentation indicates that the enrollee was found to have a left humerus fracture and rapid atrial fibrillation. 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. Specifically, the file shows that the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 23, 2021, to May 29, 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cervical collar (L0180) provided on August 6, 2021.  You asked the Plan to pay for the cervical collar. You say that the item is medically necessary. The Plan denied your request. The Plan says the member did not request, need or want these items; obtained through an unsolicited phone call.    The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.  We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the cervical collar have not been met. Therefore, we decided that the Plan does not have to pay for the cervical collar (L0180) provided on August 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the microslide consultation (CPT code 88321) provided on August 9, 2021.  You asked the Plan to pay for the microslide consultation. You say that the claim was coded correctly and that the patient saw different physicians with different specialties on the same DOS for different reasons, different diagnosis The Plan denied your request. The Plan says the total units billed exceeds the limit.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  Based on the member's claim history, this code was already billed on another claim, for the same day by another provider with the same specialty who is within the same provider group. According to NCCI, CPT code 88321 is not payable more than once per day, even if performed by separate specialties. Additionally, according to NCCI, Medically Unlikely Edits (MUEs) CMS payment policy allows only one unit of service for CPT code 88321. Therefore, the denial is upheld based on CMS guidelines as this code is only allowed once per day and the service was already paid on another claim within the same provider group. Based on this information, we decided that Medicare rules for coverage of the microslide consultation have not been met. Therefore, we decided that the Plan does not have to pay for the microslide consultation (CPT code 88321) provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (SelectMDx) provided to the enrollee on May 3, 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 there was no documented result of a prior prostate biopsy.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria has not been met. Specifically, there is no record that he has had a prior negative biopsy or that the prostate-specific antigen (PSA) has risen significantly.   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 pay for laboratory services (SelectMDx) provided to the enrollee on May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a core build-up (D2950), and resin-based composites (D2331 and D2332) provided by a participating provider on August 25, 2021.  You asked the Plan to waive the coinsurance for a core build-up and resin-based composites. You say that you do not feel like you should have to pay for this. You say that you still have a hole in your tooth. The Plan denied your request. The Plan says the correct coinsurance has been applied.  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 50% coinsurance with a maximum allowance amount of $2,500 for dental services/comprehensive dental services.    You have been asked to pay a 50% coinsurance of the allowed amount for a core build-up and resin-based composites. The total allowed amount is $389. The total amount you are being asked to pay is $194.50 ($389 x 50% = $194.50). A core build-up and resin-based composites falls within the dental services/comprehensive dental 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 coinsurance for a core build-up (D2950), and resin-based composites (D2331 and D2332) provided by a participating provider on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and supplies (K0553).  You asked the Plan to pre-approve a CGM and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the member is not checking their blood sugar four or more times a day and they are not adjusting their insulin based on the blood sugar tests.  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 perform blood glucose testing at least four times per day and 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 a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ED visit (CPT code 99283) provided on March 27, 2021.  You asked the Plan to pay for the emergency department visit. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The member was seen in the ED on March 27, 2021. One (1) unit of 99283 was previously approved/paid. There is no additional documentation supporting an additional service which was billed and remains denied. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the ED visit (CPT code 99283) provided on March 27, 2021.