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

 We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).  You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure 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 procedure 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to demonstrate the safety and efficacy of the requested procedure.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for a urinary catheter and supplies provided from June 16, 2021, to September 16, 2021.  You asked the Plan to waive the coinsurance for the catheter and supplies. You say that you feel that you should not be responsible for the coinsurance since the provider could not handle the claims in a timely manner. The Plan denied your request. The Plan says the correct coinsurance was applied.  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 20% coinsurance for durable medical equipment (DME), including catheters and supplies. Item Allowed Amount 20% Coinsurance Catheter and Supplies - June 16, 2021 $897.60 $179.52 Catheter and Supplies - July 16, 2021 $897.60 $179.52 Catheter and Supplies - August 16, 2021 $897.60 $179.52 Catheter and Supplies - September 16, 2021 $897.60 $179.52 Total:  $718.08   You have been asked to pay $718.08, which is 20% of the allowed amount for the catheter and supplies. The catheter and supplies fall within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a urinary catheter and supplies provided from June 16, 2021, to September 16, 2021.
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 a power seat elevation system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the aortography coded 75625 and the angiography services coded 75736 and 75774 provided on August 11, 2021.  You asked the Plan to pay for the aortography and the angiography services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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, we have confirmed that codes 75625, 75736, and 75774 are a column II code to column I code 37244. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the aortography coded 75625 and the angiography services coded 75736 and 75774 provided on August 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor system and standard supply allowance (CPT code(s): K0554NU and K0553NU)  You asked the Plan to pre-approve the items. You say that it is medically necessary based on type 2 diabetes mellitus without complications. The Plan denied your request. The Plan says the Medicare rules 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 you are not insulin-treated with multiple (three or more) daily administrations of insulin, or a continuous subcutaneous insulin infusion (CSII) pump and it does not show that your insulin treatment regimen requires frequent adjustment by the beneficiary on the basis of BGM or CGM testing results. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor system and standard supply allowance (CPT code(s): K0554NU and K0553NU)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided to the enrollee on July 16, 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 Medicare says screening services with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.  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 laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided to the enrollee on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office services (CPT code 99214) provided to the enrollee on August 19, 2021, by an out-of-network provider.  You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.  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 the office services (CPT code 99214) provided to the enrollee on August 19, 2021, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) provided by an out-of-network provider.  You asked the Plan to pre-approve clinical crown lengthening. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says D4249 is not a covered dental benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.          Therefore, we decided that the Plan does not have to pre-approve clinical crown lengthening (D4249) provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Lyrica caplet 75mg for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare guidance says non-injectable, self-administered drugs like Lyrica are covered by the pharmacy (drug) benefit.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the drug. Our reviewer says that  Our physician reviewer found   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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Lyrica caplet 75mg for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a partial upper denture (D5212).  You asked the Plan to pre-approve a partial denture. You say that the enrollee lost their existing partial denture in a restaurant. You also say that the enrollee needs a new one. The Plan denied your request. The Plan says partial upper denture is covered once every 5 plan years. 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 partial upper denture is listed as covered, the frequency limit has been reached. The record shows that the Plan paid for a partial upper denture that you received on November 4, 2021, less than 5 years ago. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5212).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance service, advanced life support, emergency transport, level 1
(A0427, A0425) provided on July 6, 2021.
You asked the Plan to pay for ambulance service, advanced life support, emergency transport, level 1. You say
that the transport occurred before the patient was inpatient. The Plan denied your request. The Plan says that
the ambulance services are not paid separately when the patient is inpatient.
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 has not provided us with documentation to show that the
enrollee was inpatient on this date of service. Therefore, we decided that the Plan has to pay for ambulance
service, advanced life support, emergency transport, level 1 (A0427, A0425) provided on July 6, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs are long term acute
care hospital (LTACH) appropriate and can be met and monitored at a LTACH level of care. The Plan denied
your request. The Plan says the requested LTACH admission 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 the provided documentation indicates that the enrollee has had a complicated hospital
course including sepsis and acute kidney injury. The record indicates that the enrollee is gradually improving but 
still requires acute care services. The reviewer found that the enrollee continues to receive acute care services, and 
these have not been denied. The medical record does not indicate that the enrollee requires services that she is 
not currently receiving but that would be available at the LTACH facility. Therefore, the reviewer found that the transfer 
to an LTACH facility is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Specifically, the file does not indicate
that the enrollee requires services that she is not currently receiving but that would be available at the LTACH
facility. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you fear for your safety if you are released home without professional help. You say that you are a fall risk and that SNF care will help you regain your strength. The Plan denied your request. The Plan says that the enrollee is stable, and he has no daily skilled nursing needs or complex wound care. The Plan says that the enrollee does not need daily skilled services in a SNF and that his needs are mainly custodial in nature.  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 the criteria for coverage have been met. Our physician reviewer found the enrollee has a medical history that includes hypertension and spinal stenosis. The enrollee was hospitalized with Coronavirus from December 31, 2021, through January 10, 2022, at which time he was discharged home on oxygen and with an indwelling urinary catheter for urinary retention. The enrollee presented to the Emergency Department on January 25, 2022, with a urinary tract infection and altered mental status; he was admitted to the hospital. It is documented that the enrollee does not walk at baseline. On January 26, 2022, the enrollee was more alert and was upbeat. Physical therapy documented that the enrollee requires frequent rests. The enrollee is not safe for ambulation. There are no current skilled nursing service needs identified. There are current skilled therapy service needs identified. It is medically necessary that these skilled therapy services are provided on a daily basis on an inpatient basis in a SNF 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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 pre-approve a therapeutic parenteral drug (D9610).  You asked the Plan to pre-approve the dental item. You say that you need this service. The Plan denied your request. The Plan says therapeutic parenteral drug is not listed as a covered service.  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 therapeutic parenteral drug is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a therapeutic parenteral drug (D9610).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of a new patient (CPT code 99201) provided to the enrollee on December 28, 2020.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this service is 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. In this case, we have confirmed that code 01480 is a column II code to column I code 99201. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the office or other outpatient visit for the evaluation and management of a new patient (CPT code 99201) provided to the enrollee on December 28, 2020.
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 are experiencing difficulty and a great deal of pain using your new prosthetic and you need inpatient rehab to learn to use and safely ambulate with this new prosthetic. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your current needs can be managed at a lower level of care.  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 based on the documentation provided, you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met in an alternate 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944) provided July 15, 2021.  You asked the Plan to pay for the occlusal guard. You say that you would like you dental benefit of $1,000 to apply to this service. The Plan denied your request. The Plan says this service is not covered under your benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard - hard appliance, full arch (D9944) provided July 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided from December 14, 2020, to December 19, 2020.  You asked the Plan to pay for inpatient hospital services. You say that the services provided were medically necessary and supported by the medical records. The Plan denied your request. The Plan says the billed DRG is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with secondary diagnosis E87.2 (acidosis). 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 inpatient hospital services. Our reviewer says that the billing of secondary diagnosis E87.2 is not supported in the medical record. Our physician reviewer found review of the documentation received was incomplete to reflect serum lactate levels or arterial/venous blood gas results consistent with the condition of lactic acidemia.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided from December 14, 2020, to December 19, 2020.