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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that records do not show that you can tolerate 1.5 hours of therapy per day at least 5 days per week of therapy.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0813).
You asked the Plan to pre-approve the DME. You say that you feel like you were done wrong by the company that you got the chair from. The Plan denied your request. The Plan says the DME is not necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that you have not had the wheelchair repaired. Reasonable useful lifetime of this equipment of five (5) years has not been met and records do not show there is irreparable damage due to a specific accident or to a natural disaster. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0813).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (73562) provided to the enrollee on December 22, 2020.

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 Current Procedural Terminology (CPT) code 73562-RT (1 Unit) remains not supported.

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 73562 is "Radiologic examination, knee; 3 views." 

We asked our coder 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found on December 22, 2020, the enrollee had a two view right knee series, per the report. This service should have been coded with CPT 73560 instead of CPT 73562.

We looked at this coder's review, the file, and Medicare rules. 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 radiology services (73562) provided to the enrollee on December 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code 81479) provided to the enrollee on December 29, 2020, by an out-of-network provider.

You asked the Plan to pay for the laboratory testing. 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 laboratory testing (CPT code 81479) provided to the enrollee on December 29, 2020, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty (D7310) provided on January 25, 2021; the guided tissue regeneration procedures (D4266), surgical implant placements (D6010) and bone grafts (D6104) provided on January 25, 2021, and March 8, 2021; the diagnostic consultation (D9310) provided on March 8, 2021; and the interim complete denture (D5810) provided on March 24, 2021.
You asked the Plan to pay for the dental services. You say that this bill is too expensive, and you were led to believe that these services were covered. You say you would never have received this dental work if you knew you would owe this much. The Plan denied your request. The Plan says these services are not covered under your 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. The Plan can cover up to one alveoloplasty, two surgical implant placements, and two bone grafts at the time of implant placement per year. 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 or are requested in a frequency that exceeds what is covered by the benefit. Documentation shows that on January 25, 2021, the Plan covered an alveoloplasty, two of the surgical implant placements, and two bone grafts at the time of implant placement. This means that any additional alveoloplasty, implant, and bone grafting procedures exceed the maximum frequency covered by the Plan. The remaining services, including the diagnostic consultation, guided tissue regeneration and interim denture are not listed as eligible services in the Plan's contract. Therefore, we decided that the Plan does not have to pay for the alveoloplasty (D7310) provided on January 25, 2021; the guided tissue regeneration procedures (D4266), surgical implant placements (D6010) and bone grafts (D6104) provided on January 25, 2021, and March 8, 2021; the diagnostic consultation (D9310) provided on March 8, 2021; and the interim complete denture (D5810) provided on March 24, 2021.
Your complaint about potential misinformation or misleading information from the Plan 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from
October 29, 2020, through October 31, 2020.

You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says an inpatient admission is not medically necessary.

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 pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a then 67-year-old female with no significant past medical history who fell and presented to the emergency department on October 29, 2020 with left shoulder and left upper extremity pain. She was evaluated and found to have a left humerus fracture. She was evaluated by Orthopedics. She was not felt to be a surgical candidate. She was admitted for pain control and neurovascular checks. Her condition stabilized and improved, and she was discharged home when considered medically stable on October 31, 2020. The review indicates that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two 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 pay for the acute inpatient hospital care provided from October 29, 2020, through October 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the services are considered experimental and 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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 

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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an osteogenesis stimulator, electrical, non-invasive, other than spinal applications (E0747).
You asked the Plan to pre-approve an osteogenesis stimulator. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says that medical necessity has not been established for the requested service.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an osteogenesis stimulator. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer it is established in the medical documentation that this enrollee sustained an injury on 4/30/2021 in which they sustained a fifth metatarsal fracture left side. The enrollee was placed in a fracture walking boot and asked to ambulate with a cane. The x-rays dated 7/29/2021 are assessed as being unchanged as compared to the x-rays taken right after the injury three months ago. A recalcitrant fracture/nonunion of the fifth metatarsal is noted. Therefore, the requested osteogenesis bone stimulator to treat this enrollee's fracture of the fifth metatarsal base is medically reasonable and necessary and does meet LCD Medicare coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an osteogenesis stimulator have been met. Therefore, we decided that the Plan has to pre-approve an osteogenesis stimulator, electrical, non-invasive, other than spinal applications (E0747).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you do not want to see a Plan provider. The Plan denied your request. The Plan says this service is available within your Health Plan network.
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 consultation to be provided by an out-of-network provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 30.

You asked the Plan to pre-approve the dental service. You say that the crown is medically necessary. The Plan denied your request. The Plan says a cap cannot be approved for a tooth that has an inadequate fill from a root canal treatment. The Plan also says that the requested service is not medically necessary.

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. The Plan covers the dental service when the services are medically necessary and reasonable. 

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 dental service. Our reviewer says that the crown for tooth # 30 is not medically necessary. Our physician reviewer found the provided documentation indicates that there was a root canal done on tooth # 30. The reviewer found that the root canal seal is deficient. The reviewer also found that an infection is present at the root. The reviewer found that given the presentation of the tooth with short filled sealers and a current periapical infection, there would be no medical necessity for the requested crown.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the file shows that the tooth has a poor long-term prognosis, due to a deficient root canal seal as well as infection at the root. Therefore, we decided that the Plan does not have to pre-approve a crown (D2751) for tooth # 30.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiomyopathy risk factor screening (81286, 81407, 81408, 81479) provided October 9, 2020.

You asked the Plan to pay for the cardiomyopathy risk factor screening. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this is not a Medicare-covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of the cardiomyopathy risk factor screening have not been met. Therefore, we decided that the Plan does not have to pay for the cardiomyopathy risk factor screening (81286, 81407, 81408, 81479) provided October 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated knee orthosis (L1846).
You asked the Plan to pre-approve an orthosis. You say that you feel that is medically necessary for you to have this brace. You are having a lot of pain and the only alternative would be knee replacement surgery. The Plan denied your request. The Plan says the records do not support that a custom fabricated orthosis is medically 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 pre-approve an orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is an 83 year old female with right knee osteoarthritis and right knee pain. The enrollee was trying to avoid surgery and an orthosis is reasonable in this situation. However, the documentation does not describe the enrollee trying and failing a standard prefabricated lower cost knee brace to justify the custom orthosis. Therefore, without sufficient support made for this request, the custom knee orthosis will be considered not medically necessary 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 an orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated knee orthosis (L1846).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walking boot (L4360) provided on April 6, 2021.

You asked the Plan to pay for the walking boot. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the required modifier.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that CPT code L4360 is not supported in the record. Specifically, CPT code L4360 requires a KX, GA or GZ modifier. None of the required modifiers have been billed on this claim. Based on this information, we decided that Medicare rules for coverage of the walking boot have not been met. Therefore, we decided that the Plan does not have to pay for the walking boot (L4360) provided on April 6, 2021.
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 these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. 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 Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that the enrollee's condition has improved, and he is no longer a threat to himself or others.
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 hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as he is not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and having no side effects to the medication. He is showing some ideas of reference. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he does not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.