Persius/hicric huggingface dataset:
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 SNF care is medically reasonable and necessary for your condition. The Plan denied your request. The Plan says the requested SNF care is not medically reasonable and necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, this patient does not require the necessary services on 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and three crowns (D2751 x3), or pay more for the prophylaxis (D1110) provided from August 31, 2021, to September 21, 2021.
You asked the Plan to pay for the periodic oral evaluation and crowns, and to pay more for the prophylaxis. You say that you are not able to pay these bills. The Plan denied your request. The Plan says these services are covered benefits, but you have exceeded the limits set in the subscriber agreement. The Plan also says that the annual maximum limit of $1,500.00 had been reached prior to the processing of these services and no payment can be issued.
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 offers a $1,500 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on August 31, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and three crowns (D2751 x3), or pay more for the prophylaxis (D1110) provided from August 31, 2021, to September 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve a therapeutic CGM. You say that this CGM is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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. Although the provider indicated that 3 daily injections are performed, this is not corroborated by the medical records. Based on this information, we decided that Medicare rules for coverage of a therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not require daily skilled nursing or skilled therapy in a SNF setting.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve radiofrequency ablation (RFA) services.  

You asked the Plan to pre-approve radiofrequency ablation services. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage of the RFA services have not been met.  

The Plan follows Medicare rules. Medicare rules say that before RFA services can be covered, the criteria in the Medicare rules section must be 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 radiofrequency ablation services. Our reviewer says that the requested radiofrequency ablation services are medically reasonable and necessary. Our physician reviewer found this woman has chronic axial neck pain. She had greater than 80% pain relief from each of 2 sets of cervical medial branch block (November 18, 2021 and December 2, 2021). The request is for RFA of the cervical Medial branches. In this case, the physician has followed clinical practice guidelines. The request is medically reasonable and 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 radiofrequency ablation services have been met. Therefore, we decided that the Plan has to pre-approve radiofrequency ablation (RFA) services.   

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest, abdomen, and pelvis.  You asked the Plan to pre-approve CT scans. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these tests is correct, because these CT scans are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scans. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CT scans. Our physician reviewer found the record shows that the enrollee has some dysphagia and nausea for about 3 days. The enrollee had a hiatal hernia repair about 18 months prior. No other testing is reported. The records do not support the medical necessity of these scans.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scans of the chest, abdomen, and pelvis.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82728, 83540, 83550, and 83970) provided to the enrollee on August 9, 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 services are 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 AY modifier is used when the lab services are not related to ESRD. In this case there is no modifier to indicate this would be separate from ESRD. The medical records also indicate that these lab services were related to ESRD. 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 (CPT code(s): 82728, 83540, 83550, and 83970) provided to the enrollee on August 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on August 5, 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 separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex placement procedure (22869).  You asked the Plan to pre-approve a Vertiflex placement procedure. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex placement procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered experimental/investigational. Two learned orthopedic societies have not endorsed the use of the 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 a Vertiflex placement procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex placement procedure (22869).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.
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 covered.
The Plan must follow Medicare rules. The rules say that a power seat elevation feature (E2300) is not covered. We looked at the file and Medicare rules. The services at issue are a power seat elevation system. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FISH testing (88120) provided on April 9, 2021.
You asked the Plan to pay for the FISH testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this testing was ordered solely for screening purposes.
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, the FISH testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, the documentation submitted does not include any clinical information to support why this testing was ordered or how the outcome will affect the member's treatment. Therefore, we decided that the Plan does not have to pay for the FISH testing (88120) provided on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for transthoracic echocardiography (93306) injection, octafluoropropane microspheres, per ml (Q9956) provided on May 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the outpatient service. You say that you request review of this claim for medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 transthoracic echocardiography (93306) injection, octafluoropropane microspheres, per ml (Q9956) provided on May 5, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on October 18, 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 must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain
documentation requirements must be met.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on October 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron 8mg tablets.  You asked the Plan to pre-approve Ondansetron. You say that Ondansetron is medically necessary. The Plan denied your request. The Plan says Ondansetron is not being used as a full replacement for IV anti-emetics, and therefore coverage criteria under the Part B medical benefit has not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron 8mg tablets.   Benefits for Ondansetron may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of network (OON) provider from August 20, 2021, through September 23, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the psychotherapy services (90837) rendered by the out-of-network (OON) 
provider from August 20, 2021, through September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 13, 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 must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on September 20, 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 must follow Medicare rules. Medicare rules say that for code 62320 to be covered, certain documentation requirements must be met. 

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the injection rendered on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an excision of soft tissue lesion (69145) and a tissue exam by pathologist (88305) provided on October 28, 2021, by an out-of-network provider.
You asked the Plan to pay for an excision of soft tissue lesion and a tissue exam by pathologist. 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 an excision of soft tissue lesion (69145) and a tissue exam by pathologist (88305) provided on October 28, 2021, by an out-of-network provider.