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

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous Spacer procedure.
You asked the Plan to pre-approve a Vertiflex Superion Interspinous Spacer procedure. You say that the
requested Vertiflex Superion Interspinous Spacer procedure is medically necessary. The Plan denied your
request. The Plan says the requested Vertiflex Superion Interspinous Spacer procedure is 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 Vertiflex Superion Interspinous
Spacer procedure. Our reviewer says that the requested Vertiflex Superion Interspinous Spacer procedure is not
medically necessary. Our physician reviewer found the enrollee presents with chronic low back pain and
signs/symptoms of neurogenic claudication. He is status post remote L4/5 and L5/S1 decompression and
fusion. There is imaging evidence of severe facet hypertrophy with severe central canal stenosis at L3/4, and
mild central canal narrowing at L2/3. He has reportedly failed conservative treatment. Under consideration is a
request for the Vertiflex Superion device at the L2/3 and L3/4 level. 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 as discussed above. Additionally, FDA
indication include implantation of the Superion device for the treatment of moderate stenosis at one or two
adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1
to L5. This enrollee has mild central canal narrowing at L2/3 and severe central canal stenosis at L3/4. There is
no rationale why standard surgical decompression would not be indicated. Therefore, this request for Vertiflex
Superion indirect lumbar decompression is not reasonable and medically necessary for this enrollee's medical
condition.
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 Superion Interspinous Spacer procedure have not been met.
Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous Spacer
procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS HF system.
You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF
system is medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF
system is 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 CardioMEMS HF system. Our
reviewer says that the requested CardioMEMS HF system is not medically necessary. Our physician reviewer
found the enrollee is with a nonischemic cardiomyopathy. A HeartMate 2 LVAD is in place. The enrollee's
symptoms have worsened, and he has been hospitalized multiple times.
The CardioMEMS HF system is approved by the US FDA to monitor pulmonary artery pressure and heart rate
in patients with NYHA class 3 HF who have been hospitalized during the previous year. The efficacy of the
CardioMEMS system has not been established. Further study is needed to determine the efficacy and safety of
this 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 a CardioMEMS HF system have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CardioMEMS HF system.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for respiratory virus testing provided on March 18, 2020.You asked the Plan to pay for respiratory virus testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, respiratory virus testing, 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 respiratory virus testing provided on March 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She had a left SI joint fusion and then removal of hardware along with subsequent re-instrumentation. The requested RFA of the left SI joint is considered experimental/investigational in nature and is not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea crown (D2750) for tooth #14.You asked the Plan to pre-approvethe crown for tooth #14. You say that the enrollee has tooth #13 missing, maxillary sinus is down, and an implant is not feasible. You also say that you recommend a bridge from tooth #12 to 14 in order to preserve both teeth, and replace the missing tooth.The Plan denied your request. The Plan says placing a crown on tooth #14 is not medically necessary and does not meet the coverage criteria under the enrollee's supplemental 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. The Plan covers the crown for tooth #14 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 crown for tooth #14. Our reviewer says that the service is not medically necessary. Our physician reviewer found a crown restoration (D2750) for tooth #14 does not meet the criteria for coverage since the documentation does not indicate that there is significant coronal breakdown due to caries orfracture to warrant the service.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 crown for tooth #14 have not been met.Therefore, we decided that the Plan does not have to pre-approvea crown (D2750) for tooth #14.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from
February 11, 2020 to February 12, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you never had an exam or
consultation with a surgeon. You say that you shouldn't be charged for a bill when you didn't see a surgeon.
The Plan denied your request. The Plan says the copayment applied correctly.
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 $250
copayment for outpatient hospital observation services.
You have been asked to pay a $250 copayment for the observation stay. The observation stay falls within the
"Outpatient hospital observation" benefit category. The records show that you were treating during the
observation stay. 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 observation stay provided
from February 11, 2020 to February 12, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on January 10, 2020.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says you must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on January 10, 2020.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 enrollee was admitted to the hospital for chest pain and underwent emergent three coronary artery bypass grafts. Current treatment requirements include ongoing wound care, wound VAC, NGT feeds, heparin drip, and mechanical ventilation support. The enrollee does not require services at the LTACH that are not already available at the current acute care hospital. There are no services available at the proposed LTACH that the enrollee requires that are not already available and covered at the current 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay from January 1, 2020 to January 11, 2020.You asked the Plan to waive the copayment for the SNF stay. You say that you should not be responsible for the copayment. 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 $0 copayment for per day for days 1-20 and a $178 copayment per day for days 21-100 for Medicare-covered skilled nursing facility stays. You have been asked to pay a $1,068 copayment for the SNF stay. The SNF stay falls within "Skilled nursing facility (SNF) care" 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 SNF stay provided from January 1, 2020 to January 11, 2020.Your complaint that it is the facility's fault you stayed past 20 days 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compressor identified with code E0650.
You asked the Plan to pre-approve a pneumatic compressor. 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 medically necessary.
The Plan follows Medicare rules. Medicare rules say that pneumatic compressors are only covered for certain indications. 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 pneumatic compressor. Our reviewer says that the requested item is not medically necessary. Our physician reviewer found the documentation shows that the plan has approved the segmented pump and corresponding sleeve. The segmented pump and sleeve is considered a higher level system than non segmented. Since the segmented pump and corresponding sleeve are
already approved, the requested non segmented pump would be redundant. Therefore, the enrollee does not meet criteria for the requested 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 a pneumatic compressor have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compressor identified with code E0650.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out patient services provided on January 28, 2020 by an out of network (OON) provider.You asked the Plan to pay for out patient services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the member's primary care physician did not refer these services.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 has network providers available who can provide 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 out patient services provided on January 28, 2020 by an out of network (OON) provider.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient services provided November 4, 2019 to November 27, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the 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 medical center is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the outpatient services provided November 4, 2019 to November 27, 2019.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 above. 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 enrollee required maximum assistance for mobility. The enrollee was medically stable with no evidence of need for supervision by physical medicine and rehabilitation Physician or needs acute rehab nursing care. While the enrollee may benefit further from physical therapy and occupational therapy, the enrollee does not require an intensive therapy program. The enrollee's needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care provided from November
7, 2019 to November 21, 2019.
You asked the Plan to waive the copayment for the wound care. You say that these charges are irresponsible
for a simple procedure. The Plan denied your request. The Plan says the claim was reprocessed and 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 $150
copayment for each non-surgical visit to a hospital outpatient department.
You have been asked to pay a $150 copayment for each of the wound care visits. The wound care falls within
the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" 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 wound care provided
from November 7, 2019 to November 21, 2019.
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-approveIRF care. You say that admission would help you regain strength and mobility.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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. Your medical status is not stable and latest notices indicate you are in the intensive care unit. While you may benefit from multiple therapies such as physical and occupational therapy in the future, the documentation does not support that your functional status requires an intensive rehabilitation therapy program provided in an IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided by from August 21, 2019 through August 30, 2019.You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that the rehabilitation stay should have been fully paid. You say that you should be reimbursed.The Plan denied your request. The Plan says the copayment applied correctly.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 $295 copayment each day for days 1 to 8 for Medicare-covered hospital care. $0 copayment for additional Medicare-covered days. For inpatient hospital care, the cost-sharing described above applies each time you are admitted to the hospital. A transfer to a separate facility type (such as an Inpatient Rehabilitation Hospital or Long Term Care Hospital) is considered a new admission.You have been asked to pay a $2,360 copayment for the inpatient rehabilitation stay. ($295/day x first 8 days = $2,360). The inpatient rehabilitation stay falls within the "Inpatient Hospital Care" benefit category. The records show that you were transferred to inpatient rehabilitation,which is considered a new admission. 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 inpatient rehabilitation stay provided by from August 21, 2019 through August 30, 2019.