Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided  that the  Plan does not have to pre-approve a referral  for  a wheelchair  with  an  out-of-network provider.

You asked the  Plan to pre-approve the referral.  You say that this  is medically  necessary.The Plan denied  your request. The  Plan says medically  necessary  care is  available  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  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-approvea referral  for  a wheelchair  with  an out-of-network  provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Superion interspinous spacer device.You asked the Plan to pre-approvethe device. The Plandenied your request. The Plan says this 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 the device. Our reviewer says that the requested Superion interspinous spacer device is not considered medically reasonable and necessary in this case. Our physician reviewer found that this 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 device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Superion interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex procedure).You asked the Plan to pre-approveVertiflex procedure. You say that you need this procedure.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is investigational and non-covered.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 correctin denying the request to pre-approve Vertiflex procedure. 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 remains experimental, moreresearch is needed to show its 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 Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interspinous spacer device (Vertiflex procedure)
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe preventive procedure provided on July 23, 2020.You asked the Plan to pay forthe preventive procedure. You say that the Plan told you that this provider was in-network.The Plan denied your request. The Plan says this service is 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 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 forthe preventive procedure provided on July 23, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe thoracic lumbar sacral orthosis (L0457) provided June 26, 2020.You asked the Plan to pay forthe orthosis. You say that no patient should be denied care or pain management solution because they are required to have historical documentation on record to measure pain.The Plan denied your request. The Plan says without a face-to-face encounter the ordering physician could not gather the information associated with diagnosing, treating, or managing the clinical condition for which the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) was ordered.The Plan must follow Medicare rules. Medicare rules say that as a condition for payment, a treating practitioner is required to have a face-to-face encounter with a beneficiary within the 6 months prior to prescribing items that appear on the required list. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.
Therefore, we decided that the Plan does not have to pay forthe thoracic lumbar sacral orthosis (L0457) provided June 26, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 12, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you've had several blood
draws performed at the facility and never had a copayment before. 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 $20
copayment for lab services at an in-network freestanding laboratory.
You have been asked to pay a $20 copayment for laboratory services. The laboratory services fall within the
"Outpatient diagnostic tests and therapeutic services and 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 copayment for laboratory services provided on August 12, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approvecontinued treatment with benralizumab.You asked the Plan to pre-approvethe benralizumab treatment. You say that continuation of this drug is warranted due to improvement in symptoms.The Plan denied your request. The Plan says that there is not sufficient documentation showing that this treatment was helpful.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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the benralizumab treatment. Our reviewer says that the documentation shows that this medication is medically reasonable and necessary. Our physician reviewer found the clinical note from 12/8/2020 documents improved asthma symptoms and fewer exacerbations since starting the drug.This supports that benralizumab is 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 the benralizumab treatment have been met.Therefore, we decided that the Plan has to pre-approvecontinued treatment with benralizumab.If the Plan does notagree 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 reimburse you for the cone beam CT with interpretation (D0365)
provided on July 29, 2020.
You asked the Plan to reimburse you for the dental service. You say that you are entitled to these services for
preventive health and dental evaluation. The Plan denied your request. The Plan says cone beam CT with
interpretation is not a preventive 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 items or services are not
among those covered under this benefit as it is not a preventive dental service. Therefore, we decided that the
Plan does not have to reimburse you for the cone beam CT with interpretation (D0365) provided on July 29, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approvethe SNF admission. You say that it is felt that rehabilitation with daily therapy would be helpful to help her transition back to the home.The Plan denied your request. The Plan says the enrollee has not made much progress with nearly two months of therapy in the hospital. It is not likely that daily therapy will be necessary to improve or maintain her condition.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF.The patient does not have complex wound care or other ongoing SNF level SN need. The patient's functional levelwith 
fluctuatingparticipation and limitations in carryover due to cognitive status does not support thatskilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment are needed on a daily basis at a SNF level. The patient does not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF therefore, as a practical matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 21, 2020.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be
billed with the most precise diagnosis code.
We looked at the file and Medicare rules. The file shows that the claim was not billed with the appropriate
diagnosis code. 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 pay for the emergency room (ER) services
rendered on June 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea replacement continuous glucose monitoring system for the enrollee.You asked the Planto pre-approvethe system. You say that this is medically necessary.The Plandenied your request. The Plansaysthe monitor is not eligible for replacement until March 25, 2021.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 system. Our reviewer says that the requested system is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to be a diabetic, who uses an insulin pump and a CGM. A request has apparently been made for a different type of CGM and/or additional parts for the CGM. The documentation does not explain why a switch or replacement is required. Therefore, the request is not currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the system have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea replacement continuous glucose monitoring system for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemyocardial perfusion imaging (SPECT) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe OON SPECT test. You say that the clinical information supports the need for a SPECT test.The Plan denied your request. The Plan says it is not medically necessary for the enrollee to receive care out of 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-approvemyocardial perfusion imaging (SPECT) to be provided by an out of network (OON) provide
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe deep swim spa provided on June 17, 2020.You asked the Plan to pay forthe services provided. You say that you must have aqua therapy to minimize further problems.The Plan denied your request. The Plan says the item is not covered under Medicare or the plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, wedecided that the Plan does not have to pay forthe deep swim spa provided on June 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on August 12, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because you thought telehealth copays were waived due to the pandemic.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for each specialist visit. You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment fora specialist visit provided on August 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for care in an IRF.The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of IRF 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 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure. The enrollee's medical problems arestable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided.

You asked the Plan to pay for sedation services. You say that this was medically necessary.The Plan denied your request. The Plan says this was not billed correctly.

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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that thsedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.

We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted records do not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met.Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided.
Appeal type: Imaging
Decision: Unfavorable

We decided  that  the  Plan  does not  have  to pay  for diagnostic  radiology services provided  on April  8, 2020.You asked the  Plan  to pay  for the  diagnostic  radiology.The  Plan  denied  your  request.  The Plan  says  non-emergent,  non-urgent  services  with  out-of-network  providers  require  prior  authorization.Medicare  rules  say that  plans  can require  enrollees  to get  care from  network  providers.  The  contract  with  the Plan  says  that  the  Plan  has to pay for  care from  out-of-network  providers  only  in  cases involving  emergencies, out of  area urgent  care and pre-approved care.The  requested  provider  in  this  case is not  a network  provider  with  thePlan.  The  Plandid  not pre-approve  the diagnostic  radiology  services.  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  diagnostic  radiology services provided  on April  8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe computed tomography provided on May 15, 2020.You asked the Plan to pay forcomputed tomography, abdomen and pelvis; without contrast material (74176). You say that the Plan should pay this claim.The Plan denied your request. The Plan says Original Medicare is responsible for this claim.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe computed tomography provided on May 15, 2020