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

We decided that the Plan has to pre-approve a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).

You asked the Plan to pre-approve the dental service. You say that this service is medically necessary. The Plan denied your request. The Plan says that the requested service is not allowed in a cleaning, or oral or periodontal evaluation was done in the last 12 months.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan did not provide documentation that states the full limitations of the requested service. The provided documentation lists the only limitation as being covered once every 36 months. Therefore, we decided that the Plan has to pre-approve a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355).

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 the interspinous and/or interlaminar device (CPT Code 22869), for the enrollee.
You asked the Plan to pre-approve the device. You say that the service is necessary. The Plan denied your request. The Plan says the medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's health problem.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. Contraindications include significant osteoporosis, which has not been fully elucidated and/or ruled out in this clinical setting. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of this enrollee's medical 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the interspinous and/or interlaminar device (CPT Code 22869), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on 
August 7, 2020.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted 
providers at the preferred provider rate when the services are not available from preferred providers 
in the service area. You say that the in-network benefits should be honored, and the claim processed for 
payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that services of a physical/occupational therapist 
billed as services incident to a physician/non-physician practitioner's service must meet all incident 
requirements. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services.
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical 
therapist on August 7, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for office or other outpatient visit (99214) provided on April 20, 2021.
You asked the Plan to pay for office or other outpatient visit. You say that you would like this claim
reprocessed as it is not a duplicate. The Plan denied your request. The Plan says that this claim has correctly
denied as a duplicate to a previously processed claim.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, although the Plan has argued that this is a duplicate claim, a second
claim for 99214 on April 20, 2021, was not provided. Without evidence of a claim that was paid by the Plan,
we cannot confirm that this is indeed a duplicate as the Plan argues. Therefore, we decided that the Plan has to
pay for office or other outpatient visit (99214) provided on April 20, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, surgical extraction, and deep sedation/general anesthesia services provided on August 4, 2021 by a Medicare opt out provider.

You asked the Plan to pay for the problem focused limited oral evaluation, surgical extraction, and deep sedation/general anesthesia services. You say that when you arrived at the providers office you were advised that they did not accept your insurance, but were not told that there would be no coverage. You also say that you expected to be reimbursed for these services. The Plan denied your request. The Plan says these services were rendered by a provider who chose not to receive Medicare funds.

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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, surgical extraction, and deep sedation/general anesthesia services provided on August 4, 2021 by a Medicare opt out provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 15, 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 were not billed correctly..

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code.

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory 
services rendered on April 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiology gene panel provided on June 8, 2021.

You asked the Plan to pay for the testing services. You say that the test predicts the likelihood of developing implications in various disorders. The Plan denied your request. The Plan says the tests will not affect the diagnosis or treatment of the enrollee.

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. 

We looked at the file and the rules. In this case, there are insufficient medical records to show that the results of the testing would be used in the treatment of a specific medical condition. Screening testing without signs of symptoms of disease are not covered. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the cardiology gene panel provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglasses provider on September 22, 2021.

You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says per your vision benefits, 
routine eyewear is only covered every 2 years. You received frames and lenses on October 19, 2020, which 
were paid.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan 
covers these services every 2 years.

We looked at the file and the Plan's rules. The file shows that you are eligible for the eyewear benefit every 2 
years and you received this benefit on October 19, 2020. Based on this information, we decided that the Plan's 
rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay 
for eyeglasses provider on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power mobility device (K0823) with
accessories (E0987 and E2366).
You asked the Plan to pre-approve the power wheelchair. You say that you require the power wheelchair. The
Plan denied your request. The Plan initially denied this decision, but auto-forwarded the appeal to us when they
did not make a timely reconsideration.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the power wheelchair (PWC). Our
reviewer says that the service is not medically necessary. Our physician reviewer found e documentation does
not meet the medically necessary criteria for a PWC with safety belt (E0978 x1), Batteries (E2365 x2), arm
rests per Local Coverage Determination (LCD): Power Mobility Devices (L33789). The documentation
reveals that this patient has a personal mobility deficit, but it is not clear that this deficit impairs participation in
MRADLs or why the patient's mobility deficit cannot be helped for participation in MRADLs in the home with
a manual wheelchair. The physician progress notes do not reveal a detailed neuromuscular exam. The
documentation does indicate that the enrollee's home is sufficient in size to maneuver the requested wheelchair
but it is not clear that this device will significantly improve MRADL participation in the home.
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 power wheelchair have not been met. Therefore, we decided that the Plan
does not have to pre-approve a group 2 power mobility device (K0823) with accessories (E0987 and E2366).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on August 14, 2020.
You asked the Plan to pay for drug testing. You say that this service is supported by the medical records. The Plan denied your request. The Plan says this service is not supported by the submitted documentation.
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 drug testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not note any specific concern for drug abuse or misuse. There is no evidence that concomitant urine drug screening results were reviewed and found to be abnormal prior to ordering the drug testing at issue. The drug testing at issue was not tailored to the enrollee's addictions or medications. Therefore, the documentation does not support that the provided, broad-sweeping, confirmatory drug testing was medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on August 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the requested 10
additional physical therapy visits are medically necessary. The Plan denied your request. The Plan says the
requested 10 additional physical therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not
generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive
therapy for this condition and the documentation does not indicate that the enrollee's functional level requires
the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can
be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee has
had extensive therapy and can transition to an independent home exercise program. The requested services are
not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is
not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to
prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services (A0428) on June 11, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that if you had known the cost, you would have arranged for a different mode of transportation. The Plan denied your request. The Plan says the claim was processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $265 copayment for ambulance services. The enrollee has been asked to pay a $265 copayment for ambulance services. This service falls within the Ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services (A0428) on June 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the enrollee on April 26, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied code has a status indicator of "B."
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 99100 is "Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 anesthesia services (procedure code 99100) provided to the enrollee on April 26, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673), provided on August 3, 2021.

You asked the Plan to pay for a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim.

Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675 and E0673), provided on August 3, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 the short-term acute care hospital can provide for all of the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Leuprolide Acetate (J9217) to be used in combination
with Cabazitaxel (J9043) and Carboplatin (J9045).
You asked the Plan to pre-approve Leuprolide Acetate. You say that you would like this drug to be
reconsidered for treatment of the enrollee's condition. The Plan denied your request. The Plan says the request
for Leuprolide Acetate is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Leuprolide Acetate. Our reviewer says
that Leuprolide Acetate (J9217) to be used in combination with Cabazitaxel (J9043) and Carboplatin (J9045)
does not meet the criteria for coverage. Our physician reviewer found the requested use of Leuprolide Acetate
(J9217) is not Food and Drug Administration (FDA) approved for the enrollee's diagnosis. The enrollee is
presumed to be castration resistant and no documentation of testosterone level. The plan is to treat with
Cabazitaxel and Carboplatin. Our reviewer found that the use is not supported by one of the major drug
compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved
medical journal. Our physician reviewer also found that the use is not listed as not indicated, not supported or
not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Leuprolide Acetate have not been met. Therefore, we decided that the Plan does
not have to pre-approve Leuprolide Acetate (J9217) to be used in combination with Cabazitaxel (J9043) and
Carboplatin (J9045)