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

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on August 25, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
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 that cardiac gene variant testing has limited clinical application at present and is occasionally useful in more rare familial inherited cardiac conditions. Current AHA/ACC guidelines recommend using clinical risk factor profiles and occasionally radiologic studies (CT calcium scores) for assessing cardiovascular risk and determining individual patient risk factor modification, use of lipid lowering therapies, etc. In this case, the enrollee has already known established cardiac disease and has had prior clinical evaluation and treatment for this, so a genetic risk assessment would not be relevant to her care. Cardiac gene variant testing is not currently recommended for general risk stratification and would not be considered 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment testing provided on August 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).
You asked the Plan to pre-approve the dental item. You say that you lost your upper partial denture. You say that you are having a hard time eating a healthy diet as a result. You say that you are not able to control your high blood pressure. You also say that it is medically necessary for you to have the upper denture. The Plan denied your request. The Plan says that dentures are covered once every 60 months, per patient. The Plan also says that the frequency limit has been reached.
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 and upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for an immediate upper denture that you received on January 29, 2021. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found recent notes suggest the enrollee was stable and would not require hospital services that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a carpal tunnel surgery (64721) to be provided at an outof-
network facility.
You asked the Plan to pre-approve a carpal tunnel surgery. You say that the requested service is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules 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 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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a carpal
tunnel surgery (64721) to be provided at an out-of-network facility.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the current treatment being provided is not adequate for the enrollee to be able to be discharged either to home or to a skilled nursing facility. The Plan denied your request. The Plan says you do not meet the guidelines for long term acute care services.
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 there is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals (ACHs) are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. Our reviewer found that the enrollee can remain at the current ACH until such time no acute services are required. Our physician reviewer also found that the enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.
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 the LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204), a photography of the eyes (92285) and a special eye evaluation (92060) provided on May 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit, a photography of the eye and a special eye evaluation. You say that you were referred to this provider for double vision and distorted vision. The Plan denied your request. The Plan says services were provided 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 requested provider in this case is not a network provider with the Plan. The records provided for review show that you were not referred to the non-participating provider. There is also no referring provider listed on the claim. 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 office visit (99204), a photography of the eyes (92285) and a special eye evaluation (92060) provided on May 17, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
You asked the Plan to pre-approve the complete maxillary denture and complete mandibular denture. You say that you need dentures to eat. The Plan denied your request. The Plan says these services exceed the maximum count allowed per period.
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) and complete mandibular denture (D5120) are each limited to one procedure every five plan years. The record shows that you received a complete maxillary denture (D5110) and a complete mandibular denture (D5120) on March 23, 2018 and your complete maxillary denture (D5110) and complete mandibular denture (D5120)
benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete mandibular denture (D5120).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need a high level of care so you can get back to walking and driving. You also say that a lower level of care would be a risk for you. The Plan denied your request. The Plan says this request does not meet the Plan's coverage criteria and 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that
you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that you 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 the acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulation (G0283) and manual therapy techniques (97140) provided on March 15, 2021.
You asked the Plan to pay for electrical stimulation (G0283) and manual therapy techniques (97140). You say that the Plan should pay this claim. The Plan denied your request. The Plan says these services are not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for electrical stimulation (G0283) and manual therapy techniques (97140) provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on April 22,
2021.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a telehealth visit and
you should not be responsible for the charges for a simple phone conversation. The Plan denied your request.
The Plan says the claims were processed correctly, and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50
copayment for specialist visits, including telehealth visits.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 a specialist visit provided on April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional home health physical therapy visits.

You asked the Plan to pre-approve 4 additional home health physical therapy visits. 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 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 4 additional home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee is functioning at a level commiserate with a lower level of care. As such, the quantity of requested, ongoing, home health physical therapy is not shown to be 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 4 additional home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Thallium tl-201 thallous chloride represented by code A9505 and the Aminophyllin injection represented by code J0280 provided on March 15, 2021.

You asked the Plan to pay for codes A9505 and J0280. 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 codes A9505 and J0280.

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 A9505 is Thallium tl-201 thallous chloride, diagnostic, per millicurie. The definition of code J0280 is Injection, aminophyllin, up to 250 mg. 

We find that CPT codes A9505 and J0280 are not supported in the medical record. Specifically, the documentation submitted did not support that Thallium tl-201 thallous chloride was administered on the billed date of service. The records indicate that an injection of Technetium Tc-99m sestamibi was administered. There is a more appropriate code, A9500 that should be used to bill for this service. The documentation submitted also did not support that Aminophyllin was injected on the billed date of service. The records indicate that Dipyridamole was injected. There is a more appropriate code, J1245 that should be used to bill for this service. Based on this information, we decided that Medicare rules for coverage of codes A9505 and J0280 have not been met. Therefore, we decided that the Plan does not have to pay for Thallium tl-201 thallous chloride represented by code A9505 and the Aminophyllin injection represented by code J0280 provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the P-stim auricular nerve acupuncture device (64555 and L8679) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the P-stim device. You say that based on the enrollee's history and diagnoses, the provider is recommending the neurostimulator to decrease pain. 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. This device is non-covered when used for acupuncture for any indication.
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 the P-stim auricular nerve acupuncture device (64555 and L8679) to be provided 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 chiropractic services rendered on May 10, 2021, to May
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. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. The file shows that the
chiropractor billed procedure codes 72040 (radiologic examination, spine, cervical; 2 or 3 views), 72100
(radiologic examination, spine, lumbosacral; 2 or 3 views), and 99202 (office visit). Therefore, we decided that
the Plan does not have to pay for the chiropractic services rendered on May 10, 2021, to May 13, 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 you need more rehabilitation care than your current
skilled nursing facility is able to provide. You feel you will not be able to walk again without more therapy.
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing
skilled therapy needs are being met in the current skilled nursing facility.
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment testing provider on June
30, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.
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 that cardiac gene variant testing is not currently recommended for general
risk stratification based on AHA/ACC published guidelines and would be considered investigational for this
purpose at this time.
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 cardiovascular risk assessment testing provider on June 30, 2020.