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

We decided that the Plan does not have to pre-approve a colonoscopy to be provided in a hospital facility.
You asked the Plan to pre-approve a colonoscopy to be provided in a hospital facility. 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 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 colonoscopy to be provided in a
hospital facility. Our reviewer says that the requested items/services are not considered medically reasonable
and necessary in this case. Our physician reviewer found the documentation shows that the enrollee has had a
history of anesthesia complications. There is no specific indication for the colonoscopy to be provided in the
hospital setting. The procedure can be appropriately completed in an ambulatory surgical center. The
documentation shows that the enrollee does not have a diagnosis/condition that meets criteria for the requested
services to be provided by a hospital 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 a colonoscopy to be provided in a hospital facility have not been met.
Therefore, we decided that the Plan does not have to pre-approve a colonoscopy to be provided in a hospital
facility.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve these services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is not in 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 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 out of network physician services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high frequency chest wall oscillation air-pulse generator
system (CPT code E0483), for the enrollee.
You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your
request. The Plan says the Medicare rules have not been met.
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 system. Our physician reviewer
found the review indicates that there is no documentation of a confirmed diagnosis of bronchiectasis. The
denial of a high frequency chest wall oscillation air-pulse generator system in the setting of chronic obstructive
pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis is appropriate given the
clinical scenario and the guidance presented above. The review has determined that the medical records
provided do not meet the requirements listed in the LCD for Medicare coverage.
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 system have not been met. Therefore, we decided that the Plan does not
have to pre-approve high frequency chest wall oscillation air-pulse generator system (CPT code E0483), for the
enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitor supplies to be provided by an out-of-network provider.
You asked the Plan to pre-approve continuous glucose monitor supplies. You say that you are dissatisfied with the in-network provider. 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 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 continuous glucose monitor supplies to be provided by an out-of-network provider.
Your complaint about lapses in care by the in-network 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July
5, 2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that the hospital called the
ambulance company even though you had another membership elsewhere. The Plan denied your request. The
Plan says you have been charged the correct cost sharing 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 $200
copayment for each one-way ambulance trip.
You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls
within the Ambulance Services 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
the ambulance transport provided on July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the manual therapy techniques (97140) provided on January
5, 2021, through May 20, 2021.
You asked the Plan to pay for the manual therapy techniques. You say that you believe these services have
been billed incorrectly. The Plan denied your request. The Plan says the only services that are covered when
performed by a chiropractor are the manual manipulation of the spine to correct subluxation.
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. Therefore, we decided that
the Plan does not have to pay for the manual therapy techniques (97140) provided on January 5, 2021, through
May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crowns for tooth #14 and #15.
You asked the Plan to pre-approve the crowns. You say that if you don't get the crowns you will have to get
two teeth extracted. You say that dental extractions can cause potential heart infection and you are afraid to get
extractions. The Plan denied your request. The Plan says that your crowns were not inserted at least 60 months
ago.
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. The Plan says that crowns are only covered once every 60 months. The Evidence
of Coverage only lists a frequency limit for removable and fixed protheses. Crowns are not considered a
removable and fixed prosthesis. The Plan did not submit coverage documentation showing that crowns are only
covered once every 60 months. Therefore, we decided that the Plan has to pre-approve crowns for tooth #14
and #15.
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 upper and lower dentures.
You asked the Plan to pre-approve upper and lower dentures. You say that dentures are medically necessary.
The Plan denied your request. The Plan says dentures are not a covered 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 more than 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 upper and lower dentures.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the RFA procedure (CPT code(s): 64636 and 64635),
for the enrollee.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services.
The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's
records show they already had two radiofrequency sessions in the lumbar/sacral spine region in the twelve (12)
months prior to the October procedure, both in April 2021. The Plan states the enrollee's records show that they
only obtained pain relief for approximately three (3) months from the April RFAs.
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 services. Our physician reviewer
found there have already been two (2) injections in the past 12 months. Also, not enough pain relief was
documented.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve the RFA procedure (CPT code(s): 64636 and 64635), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing of both lower
quadrants (D4341).
You asked the Plan to pre-approve periodontal scaling and root planing of the lower quadrants. You say that
the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says
medical necessity rules for the requested services have not been met.
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 periodontal
scaling and root planing of the lower quadrants 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 periodontal scaling and root planing of
the lower quadrants. Our reviewer says that the requested services are not medically reasonable and necessary
in this case. Our physician reviewer found that the supplied photographs show some light tartar around the
lower teeth, and along with the mild probing depths of only 4 mm or less, it would appear that the slightly
increased probing depths are likely due to gingival inflammation. It does not appear that there is any substantial
periodontal disease ongoing. Without exposed root surface, there can be no scaling and debridement of those
surfaces. Without a showing of loss of supporting bone, the criteria for scaling and root planing is not met.
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 periodontal scaling and root planing of the lower quadrants have not been met.
Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing of both
lower quadrants (D4341).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultraviolet light therapy for the enrollee.
You asked the Plan to pre-approve ultraviolet light therapy. You say that this treatment is medically necessary
for lichen planus and psoriasis. The Plan denied your request. The Plan says Medicare coverage criteria are not
met.
The Plan must follow Medicare rules. Medicare covers this treatment for treatment of intractable, disabling
psoriasis, and only after the psoriasis has not responded to more conventional treatment. Based on the medical
records provided, the enrollees condition does not meet these criteria. Therefore, we decided that the Plan does
not have to pre-approve ultraviolet light therapy for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve services with an out of network gastroenterologist.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested
provider. The Plan denied your request. The Plan says this provider is not in 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 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 services with an out of
network gastroenterologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically necessary. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies
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 there are currently no clinical indications for this technology.
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 device is experimental. More research is needed to show safety and efficacy.
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: 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 you feel your life is in danger. The Plan denied your request. The Plan says your request is not medically necessary because your records show you do not have a condition complex enough to require more than twenty-five (25) days of continued inpatient hospital care with daily doctor visits and specialized nursing.
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 you appear to be improving and should only require short-term additional acute care services that can be safely administered at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH is not supported or medically necessary due to it not being clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use as bone graft material.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from December 17, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that you cannot be safely discharged home at this time. The Plan denied your request. The Plan says the stay is not medically necessary.
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 daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from December 17, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal surgery (procedure code 63048).
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the extra procedure to remove the bone is included with the other procedures, and is not approved separately.
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 63048 is "Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)." We asked our 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the requested cannot be billed. Only one level (L3-3) is decompressed. The only correct code in this case would be CPT 63047. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for spinal surgery (procedure code 63048).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 19, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 19, 2021