Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight home health speech therapy visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says the diagnoses used for the request do not support medical necessity.
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 visits. Our reviewer says that the requested visits are not medically reasonable or necessary. Our physician reviewer found there are no documented skilled speech therapy needs in the home. As such, the requested ongoing visits are 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight home health speech therapy visits for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the crown for tooth #5. We decided that the Plan does not have to pre-approve the crown for tooth #13.
You asked the Plan to pre-approve the crowns. The Plan says that medical necessity was not established for either tooth.
We decided that the Plan has to pre-approve the crown for tooth #5.
Our review says that the dental record and radiographs indicate that tooth #5 has a large defective restoration covering three surfaces. Our reviewer says that a crown restoration for this tooth meets the criteria for coverage. Therefore, we decided that the Plan has to pre-approve the crown for tooth #5.
We also decided that the Plan does not have to pre-approve the crown for tooth #13.
Our reviewer found that tooth #13 has caries on the distal surface which appears to be restorable with a filling. Our reviewer says that tooth #13 does not meet the criteria for coverage for a crown restoration Therefore, we decided that the Plan does not have to pre-approve the crown for tooth #13.
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 an excision of abdominal skin (15830) and suction-assisted lipectomy of trunk (15877).
You asked the Plan to pre-approve an excision of abdominal skin and suction-assisted lipectomy of trunk. You say that the requested procedure is not cosmetic. The Plan denied your request. The Plan says medical necessity rules for the requested procedure have 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 an excision of abdominal skin and suction-assisted lipectomy of trunk. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that you have lost weight through diet and exercise and are still losing weight. The record provided does not indicate that you have intertrigo refractory to medical treatment. The photographs provided do not indicate that the pannus extends beneath the pubis. The elements of the coverage criteria are not satisfied.
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 excision of abdominal skin and suction-assisted lipectomy of trunk have not been met. Therefore, we decided that the Plan does not have to pre-approve an excision of abdominal skin (15830) and suction-assisted lipectomy of trunk (15877).
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 an intensive rehabilitation program is not medically necessary.
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was evaluated in the Emergency Department for altered mental status. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on May 10, 2021.
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that you were told dentistry was covered when you signed up for the Plan and the bill should get paid directly. The Plan denied your request. The Plan says the claim processed correctly.
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 Plan is only obligated to pay 50% of the cost for the prophylaxis and periodic oral evaluation from an out-of-network provider. You are responsible for any amount greater than the payment made by the Plan to the out-of-network provider. Therefore, we decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent screening (87481, 87491, 87529, 87591, 87640, 87651, 87653, 87661, 87798, 87801) provided on June 22, 2021.
You asked the Plan to pay for infectious agent screening. You say that this should be covered. The Plan denied your request. The Plan says this was a screening service.
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, infectious agent screening, 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 infectious agent screening (87481, 87491, 87529, 87591, 87640, 87651, 87653, 87661, 87798, 87801) provided on June 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral lumbar 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 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 enrollee has back pain and underwent two prior medial branch block (MBB)/facet joint injections on May 21, 2021 and August 31, 2021 with documented successful pain reduction. However, there is no documentation of injections to the requested area of L5 to S1. The criteria for coverage are not met and the RFA is 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 bilateral lumbar radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L5-S1 radiofrequency ablation 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 L4-L5 can be approved, but L5-S1 cannot be approved at this time.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that there have not been at least three months of moderate to severe pain that hasn't responded to conservative care. There is no documentation provided indicating that the pain is not associated with radiculopathy or neurogenic claudication. There is no documentation provided indicating that the facet joint is the main source of pain. The enrollee did not have two medial branch blocks with 80% pain relief at the requested site. Therefore, it is not medically necessary or reasonable for this enrollee to have the requested procedure. 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 L5-S1 radiofrequency ablation for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942)
provided on October 21, 2020.
You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like
reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation
does not support the additional unit of this service that was 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 76942 is ultrasonic guidance for needle placement (e.g.,
biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
We asked our coder 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 ultrasonic guidance for needle placement. Our reviewer
says that the additional unit of CPT code 76942 does not meet criteria for billing or reimbursement
consideration. Our reviewer found the provider billed CPT 76942 twice, however the documentation states,
"Laterality: left; Injection technique: single-shot; Guidance: ultrasound guided." Documentation does not
support a second unit of service for this date.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the ultrasonic guidance for needle placement have not been met. Therefore, we
decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided
on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81201, 81295, 81298, 81317,
81407, 81408, and 81432 provided on March 22, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes 81201, 81295, 81298, 81317, 81407, 81408, and 81432 are not supported in the
medical record. Specifically, this service should be billed with code 81479. In addition, the approved DEX-Z
code should be entered adjacent in the comment/narrative field for the test. Based on this information, we
decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided
that the Plan does not have to pay for the laboratory services coded 81201, 81295, 81298, 81317, 81407,
81408, and 81432 provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care office visit (99203) provided on June 21, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $65 copayment for urgently needed services. You have been asked to pay a $65 copayment for the urgent care visit provided. 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 the urgent care office visit (99203) provided on June 21, 2021
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 29, 2021.
You asked the Plan to pay for psychotherapy services. You say that the requested services were a necessity for the enrollee's care. 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 will attempt to consult with the enrollee's attending or primary care 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 records do not document an attempt to consult with, or a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on April 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pulp cap (D3110).
You asked the Plan to pre-approve the pulp cap. The Plan denied your request. The Plan says this service is not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a pulp cap (D3110).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.
You asked the Plan to pre-approve Botox. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that localization procedures would not be expected for easily targeted
muscles and, therefore, would not be considered medically reasonable and necessary.
The Plan follows Medicare rules. Medicare rules say that Botox can be covered if the LCD 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 Botox. Our reviewer says that Botox is
not medically reasonable and necessary for the enrollee. The patient was diagnosed with incisional hernia
without obstruction or gangrene. Botox was requested. She had undergone abdominal hysterectomy surgery in
2019 due to endometrial cancer and later developed the hernia. It was noted that she would require abdominal
wall reconstruction and repair of multiple hernias. The Botox is intended to be given weeks prior to the
procedure to minimize surgical complications. The patient does not have a covered indication for Botox. The
request for Botox will be considered not medically necessary due to not having an FDA-approved indication.
Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Botox.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve Botox for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the home sleep test (G0399), magnetic resonance imaging (MRI) of the abdomen (741836) and ultrasound of the abdomen (76700), provided on April 23, 2021, May 9, 2021, and May 29, 2021.
You asked the Plan to waive the copayment for the home sleep test, MRI, and ultrasound. You say that the services should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.
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 $200 copayment for a MRI, a $45 copayment for ultrasounds and a $45 copayment for diagnostic services for outpatient diagnostic tests and therapeutic services and supplies.
You have been asked to pay a $200 copayment for a MRI, a $45 copayment for a ultrasound and a $45 copayment for a diagnostic service for the home sleep test, MRI, and ultrasound. These services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 the home sleep test (G0399), magnetic resonance imaging (MRI) of the abdomen (741836) and ultrasound of the abdomen (76700), provided on April 23, 2021, May 9, 2021, and May 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits (99204, 99214) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve office visits. You say that this provided has been recommended by your doctors. The Plan denied your request. The Plan says the care you need is available in-network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.

We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office visits (99204, 99214) to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections (11901, J3301) to be provided by an OON
provider.
You asked the Plan to pre-approve injections. You say that the requested provider is more specialized than the
in-network providers. The Plan denied your request. The Plan says this is available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
injections (11901, J3301) to be provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopy services provided on January 30, 2019.
You asked the Plan to pay for the services provided. You say that the records support the services. The Plan denied your request. The Plan says the services are not separately reported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 76000 is fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time. Services integral to accomplishing a procedure are considered bundled into that procedure. Fluoroscopy reported as CPT code 76000 shall not be reported with spinal procedures. We find that CPT codes 20936 and 20930 are bundled codes. No separate payment is ever made. 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 fluoroscopy services provided on January 30, 2019.