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

 We decided that the Plan does not have to pre-approve a continuous glucose monitor.  You asked the Plan to pre-approve the monitor. You say that this should be covered, as the enrollee needs check blood sugars 3-4 times a day. The Plan denied your request. The Plan says the criteria is 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 the enrollee does not use insulin with at least three daily injections or 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with claudication. The record indicates that the enrollee has moderate to severe central stenosis at L4-L5, the level requested for treatment and and an unquantified degree of scoliosis. 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the manual manipulation (98941) and to pay for the non-covered chiropractic services (99202, 72100, 72040) provided on July 23, 2021.  You asked the Plan to waive the deductible for the manual manipulation and to pay for the non-covered chiropractic services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the manual manipulation is a covered benefit and the correct amount applied to your deductible for code 98941. Codes 99202 (office visit), 72100 (x-ray), and 72040 (x-ray) are not covered when billed by a chiropractor.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $203 deductible which applies to Chiropractic services.   The item or service you asked the Plan to waive the deductible for falls within the benefit category Chiropractic services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $203 deductible which applies to Chiropractic services. This cost sharing is a contractual obligation that had not been met at the time the manual manipulation (98941) was received on July 23, 2021.   The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the office visit (99202), and the x-rays (72100 and 72040) are not manual manipulation of the spine.  Therefore, we decided that the Plan does not have to waive the deductible for the manual manipulation (98941) and to pay for the non-covered chiropractic services (99202, 72100, 72040) provided on July 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on July 20, 2021.  You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says this test is not reasonable and 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a normal digital rectal examination and a prostatic specific antigen level of 3. The record as provided is insufficient to determine the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 the testing have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx test provided to the enrollee on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on June 23, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the repair/modification of a hearing aid (V5014) provided June 23, 2021.  You asked the Plan to pay for the hearing aid repair/modification. You say that this service should be included in your hearing exam. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage.   Though the Plan offers hearing benefits in excess of Medicare coverage, the billed hearing aid repair/modification is not among those covered services. Therefore, we decided that the Plan does not have to pay for the repair/modification of a hearing aid (V5014) provided June 23, 2021.   Your complaint about how the service was billed and this service not being included in the billing of a hearing exam is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99204) provided on July 24, 2021.  You asked the Plan to pay for code 99204. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. The rules also state that any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.    We find that CPT code 99204 is not supported in the medical record. Specifically, the records show that this service was provided in the emergency department and should be billed with an emergency department visit code. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99204) provided on July 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).  You asked the Plan to pre-approve the complete maxillary denture. You say that you never received nor were you fitted for dentures. You also say that you would like to get your benefit back and move forward with the new dentist. The Plan denied your request. The Plan says this service does not meet the frequency requirements of the Plan.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, complete maxillary denture (D5110) is limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) on October 21, 2020 and your complete maxillary denture (D5110) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).   Your complaint about your dissatisfaction with your previous dental provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 3 additional massage therapy visits provided from August 3, 2021 to September 27, 2021.  You asked the Plan to pay for the 3 additional massage therapy visits. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says you are only covered for up to 6 massage therapy visits per year. The Plan says you have already used all 6 massage therapy visits under the Plan's supplemental benefit.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The Plan offers a massage therapy benefit that exceeds Medicare coverage.  We looked at the file and the Plan's rules. The file shows that the Plan's supplemental massage therapy benefit allows 6 visits per year. The file shows that you have used all 6 visits and you are responsible for any additional massage therapy visits. Therefore, we decided that the Plan does not have to pay for the 3 additional massage therapy visits provided from August 3, 2021 to September 27, 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 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 only requires short-term additional acute care services that can safely be administered at the current facility. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 2, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay more for the periodic oral evaluation and prophylaxis. You say that in the 2021 Summary of Benefits it clearly states that you will be responsible for a $65 copay OON. You also say that the Plan's official benefits document does not use the in-network fee schedule (INFS) and it is this provision that you appeal for the lack of information. The Plan denied your request.  The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.  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, you are responsible for a 50% coinsurance for both the periodic oral evaluation (D0120) and prophylaxis (D1110), plus the difference between the billed amount and the allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis (D1110) provided on August 2, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral evaluation (D0120) provided by an opt out provider on June 7, 2021.  You asked the Plan to pay for prophylaxis and a periodic oral evaluation. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says this provider has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral evaluation (D0120) provided by an opt out provider on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mastopexy and excision, excessive skin and subcutaneous tissue surgery.  You asked the Plan to pre-approve mastopexy and excision, excessive skin and subcutaneous tissue surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    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 mastopexy and excision, excessive skin and subcutaneous tissue surgery. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our reviewer found the enrollee has had a panniculectomy and now has excess skin. The records do not document an attempt at conservative treatment since the panniculectomy. The record indicates that the reason for the mastopexy is related to body contouring. The record presented supports that the requested procedures are cosmetic in nature. Therefore, the enrollee does not meet criteria for the requested 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 mastopexy and excision, excessive skin and subcutaneous tissue surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve mastopexy and excision, excessive skin and subcutaneous tissue surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 17, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from January 17, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from January 17, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of January 17, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond January 17, 2022, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from January 17, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 17, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation or inpatient hospital care (99235) provided on August 9, 2021.
You asked the Plan to pay for code 99235. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 99235.
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 99235 is Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.
We find that CPT code 99235 is not supported in the medical record. Specifically, the enrollee was admitted on a different date of service. Based on this information, we decided that Medicare rules for coverage of code 99235 have not been met. Therefore, we decided that the Plan does not have to pay for the observation or inpatient hospital care (99235) provided on August 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care.  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 acute inpatient rehabilitation facility (IRF) admission and services.