Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy visits.

You asked the Plan to pre-approve physical therapy. You say that you will benefit from skilled therapy and a
progressive exercise program. The Plan denied your request. The Plan says the denial of authorization for
additional physical therapy is correct.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 physical therapy. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific
and effective therapy for your condition beyond what was already approved by the Plan. You have had prior
therapy and the records do not demonstrate that the unique skills of a professional therapist are required to
safely and effectively provide treatment, that the services can be safely and effectively performed only by a
therapy, or under the supervision of a therapist. You can transition to a home exercise program with the already
approved therapy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99212) and removal of ear wax (69210) provided on February 11, 2021.
You asked the Plan to waive the copayment for an office visit and a procedure. You say that you visited the provider on February 4th and the procedure was not done correctly. You also say that you returned on February 11th and the procedure was done correctly. You say that you should not have a cost share for the second date of service. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 $50 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $50 copayment for an office visit with a specialist. The EOC confirms that $50 is the required copayment for this service. An office visit with a specialist 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 for an office visit with a specialist (99212) and removal of ear wax (69210) provided on February 11, 2021.
Your complaint about services potentially not being done correctly 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) 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 the member does not meet the criteria for an implanted spinal stimulator.

The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of dorsal column or depth brain stimulators or services and supplies related to such implantation, unless patients have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation and that such screening must include psychological, as well as physical evaluation. 

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 these services are not medically reasonable and necessary for the enrollee in this case. The enrollee is taking Duloxetine and Gabapentin. He has not had prior spine surgery. He has degenerative spine changes on imaging. He was unable to complete a course of physical therapy. He had a psychological evaluation (however, the providers credentials were not specified, ie, there was no indication if the provider was a license psychologist or psychiatrist). Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 percutaneous implantation of neurostimulator electrode array, epidural (63650) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve arch supports (L3050).

You asked the Plan to pre-approve arch supports. You say that the requested items are a necessity for your care. The Plan denied your request. The Plan says these items are not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve arch supports (L3050).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network pain management specialist.
You asked the Plan to pre-approve these services. You say that you need a medication refill. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network pain management specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the total electric hospital bed and mattress provided on January 28, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the hospital bed. You say that durable medical equipment is covered, and your primary care physician submitted a referral for your hospital bed due to GERD and horrible arthritis pain. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. 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 total electric hospital bed and mattress provided on January 28, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, Knee orthoses, and suspension
sleeve provided on November 24, 2020.

You asked the Plan to pay for the lumbar-sacral orthosis (L0650), Knee orthoses (L1851), and suspension sleeve (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the ship date indicated on the submitted packing slip is after the billed date of service.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The claim date is before the ship date and date of delivery. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, Knee orthoses, and suspension sleeve provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Neurology and Neuromuscular Procedures represented by codes 95885, 95908, 95937, and 95940 provided on October 21, 2020.
You asked the Plan to pay for codes 95885, 95908, 95937, and 95940. You say that the medical records support the billing of CPT codes 95885, 95908, 95937, and 95940 provided on October 21, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95885, 95908, 95937, and 95940 provided on October 21, 2020.
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 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95908 is Nerve conduction studies; 3-4 studies. The definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95940 is Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure). 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 codes 95885, 95908, 95937, and 95940. Our reviewer says that the medical records do not support the billing of CPT codes 95885, 95908, 95937, and 95940 provided on October 21, 2020. Our physician reviewer found the documentation submitted was reviewed and the medical records do not support the billing of codes 95885, 95908, 95937, and 95940 provided on October 21, 2020. The documentation submitted does not include enough information to confirm a qualified healthcare provider was in the operating room for supervision. Documentation supports supervision was via internet. Code 95940 is not supported. The operative report does not include enough detail to confirm this procedure is separate from TO4 testing, which is included in another service provided. Code 95937 is not supported. Code 95885 and code 95908 are not supported by the documentation. Procedural report does not include documentation of Needle electromyography, and Nerve Conduction testing to confirm these services were performed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95885, 95908, 95937, and 95940 have not been met. Therefore, we decided that the Plan does not have to pay for the Neurology and Neuromuscular Procedures represented by codes 95885, 95908, 95937, and 95940 provided on October 21, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the knee x-ray (73564 26) provided on January 20, 2021.

You asked the Plan to pay for the knee x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that this service has been paid on a previous claim.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan states that this service has already been paid. The documentation submitted does not include any evidence of a paid claim. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor Therefore, we decided that the Plan has to pay for the knee x-ray (73564 26) provided on January 20, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Neurology and Neuromuscular Procedures represented by codes 95955, 95885, and 95911 provided on November 5, 2020.
You asked the Plan to pay for codes 95955, 95885, and 95911. You say that the medical records support the billing of CPT codes 95955, 95885, and 95911 provided on November 5, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95955, 95885, and 95911 provided on November 5, 2020.
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 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and
latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of code 95911 is Nerve conduction studies; 9-10 studies. 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 codes 95955, 95885, and 95911. Our reviewer says that the medical records do not support the billing of CPT codes 95955, 95885, and 95911 provided on November 5, 2020. Our physician reviewer found the documentation submitted was reviewed, and the medical records do not support the billing of codes 95955, 95885, and 95911 provided on November 5, 2020. The procedure report indicates a baseline was performed. CPT 95955 is an inappropriate code to report for this service. For codes 95885 and 95911, these procedures were not documented in the procedure report to confirm if performed, therefore cannot be verified. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95955, 95885, and 95911 have not been met. Therefore, we decided that the Plan does not have to pay for the Neurology and Neuromuscular Procedures represented by codes 95955, 95885, and 95911 provided on November 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided on December 31, 2020.
You asked the Plan to pay for medical supplies. You say that these items were provided at your expense. The Plan denied your request. The Plan says these items were not billed with valid codes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes
have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for medical supplies (S1015, S8301) provided on December 31, 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 reconsideration because the LTACH admission is medically necessary. The Plan denied your request. The Plan says the member does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.

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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no trial of previous viscosupplementation.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 injection. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed one viscosupplemental treatment such as Orthovisc and Synvisc/Synvisc One. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Gel-One is not approved as step criteria have not been met. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on March 3, 2021.
You asked the Plan to waive the coinsurance for an injection. You say that you would like to appeal these charges. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $2,930.40. The total amount you are being asked to pay is $586.08 ($2,930.40 x 20% = $586.08). The correct coinsurance has been applied to the injection that was provided. An injection falls within the
Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection provided by a participating provider on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740 x2), the prefabricated post and core in addition to crown (D2954) and the core buildup, including any pins when required (D2950).
You asked the Plan to pre-approve the dental services (D2740, D2954, D2950). You say that you aim to maintain a healthy lifestyle, which includes having good dental health. The Plan denied your request. The Plan says the requested services are not covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crown - porcelain/ceramic (D2740 x2), the prefabricated post and core in addition to crown (D2954) and the core buildup, including any pins when required (D2950).