Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care would provide the enrollee with a
comprehensive approach in order to rehabilitate successfully. The Plan denied your request. The Plan says rules
for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 that 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 pneumoperitoneum and a right hip infection. The enrollee does not require treatment
by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is
no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 12, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that there should be a $0 copayment for the colonoscopy. The Plan denied your request. The Plan says you have been asked to pay 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 $175 copayment for each visit for Medicare-covered outpatient hospital services. You have been asked to pay a $175 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows a diagnosis code for blood in stools which makes the colonoscopy diagnostic in nature. 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 colonoscopy provided on October 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. 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. 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications. The enrollee had stable vital signs. The enrollee required maximal assistance with bed mobility. The enrollee has ongoing cognitive deficits. The documentation does not support that the enrollee requires the specialized skill, knowledge and judgment of a skilled professional nurse or a qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that the enrollee requires skilled nursing or therapy services on a daily basis. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve revascularization surgery (37227).
You asked the Plan to pre-approve revascularization surgery. You say that this procedure is medically necessary. The Plan denied your request. The Plan says the requested surgery 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 revascularization surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient's completely normal findings on the left do not explain the patient's bilateral symptoms. The patient's ankle-brachial indexes (ABIs) are normal bilaterally. The patient does have a history of back surgery and there is insufficient detail with respect to the characteristics of the patient's leg pain. Additionally, there is an absence of a pulse examination in the medical records. It is unclear what efforts at conservative management of been attempted but there is evidence that the patient has not stopped smoking. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve revascularization surgery (37227).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two periodic oral evaluations, bitewing x-rays, prophylaxis, preventive procedure, periodontal scaling and root planing, and adjunctive procedure provided on June 24, 2020, and December 11, 2020.
You asked the Plan to pay for the dental services. You say that you would like these services to be covered. The Plan denied your request. The Plan says these services were rendered by a Medicare opt out provider. The Plan also says that services performed by a privately contracted provider are not covered.
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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the two periodic oral evaluations, bitewing x-rays, prophylaxis, preventive procedure, periodontal scaling and root planing, and adjunctive procedure provided on June 24, 2020, and December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the limited oral evaluation (D0140), the panoramic x-ray (D0330), the extraction (D7210), and the unspecified preventive service (D1999) provided on September 16, 2020.
You asked the Plan to reimburse you for the dental services. You say that these services should have been paid as part of your $1,000 dental reimbursement per year. The Plan denied your request. The Plan says the provider in this case has opted out of Medicare. The Plan also says that payment cannot be made for dental services performed by a dentist who has opted out of Medicare.
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 reimburse you for the limited oral evaluation (D0140), the panoramic x-ray (D0330), the extraction (D7210), and the unspecified preventive service (D1999) provided on September 16, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.
You asked the Plan to pay for the ambulance services. You say that you fell out of your bed and needed assistance getting back up only. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 23, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99233) provided October 12, 2020.
You asked the Plan to pay for the physician services. You say that the claim should be paid. The Plan denied your request. The Plan says the deductible has not been met and the enrollee is responsible for paying the deductible before the plan is liable.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for covered services. This cost sharing is a contractual obligation that had not been met at the time the physician services was received on October 12, 2020. Therefore, we decided that the Plan does not have to pay for physician services (99233) provided October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).
You asked the Plan to pre-approve Superion interspinous spacer (Vertiflex device). 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 Superion interspinous spacer (Vertiflex
device). Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the enrollee has back pain and a diagnosis of spondylosis
(degenerative spinal disease). The Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device. Therefore, the enrollee does not meet criteria for the requested 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 Superion interspinous spacer (Vertiflex device) have not been met. Therefore,
we decided that the Plan does not have to pre-approve Superion interspinous spacer (Vertiflex device).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from September 15, 2020 to September 18, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
The Plan must follow Medicare rules. The rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis. We looked at the file and Medicare rules. The diagnosis code G96.19 was not deleted until October 1, 2020. In this case, the date of service was in September of 2020, which means diagnosis code G96.19 was payable for the dates of service at issue in this appeal. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from September 15, 2020 to September 18, 2020.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy electrical pump (E2402) provided on November 21, 2020.
You asked the Plan to waive the coinsurance for a negative pressure wound therapy electrical pump. You say that the requested item should be covered because it is part of a procedure and you were not aware it would be billed additionally. The Plan denied your request. The Plan says the correct coinsurance was 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 20% coinsurance for each Medicare-covered durable medical equipment item. You have been asked to pay $260.00, or 20% of the Medicare-allowed amount of $1,300.00, for a negative pressure wound therapy electrical pump. A negative pressure wound therapy electrical pump falls within the "Durable medical equipment (DME) and related 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 coinsurance for a negative pressure wound therapy electrical pump (E2402) provided on November 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is medically
necessary for the enrollee because conservative therapy has failed. The Plan denied your request. The Plan says
the requested service is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee has chronic low back and spinal stenosis. However, a Vertiflex
interspinous spacer is considered an experimental/investigational device and is not included in the treatment
algorithms of learned societies.
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 procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT).
You asked the Plan to pre-approve Proton treatment delivery; complex (77525). You say that PBRT is
medically necessary for continued treatment. The Plan denied your request. The Plan says a review of the
literature indicates that PBRT is not the standard of care for prostate cancer and should only be performed
within the context of a prospective clinical trial.
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 Proton treatment delivery; complex
(77525). Our reviewer says that the requested services are not considered medically reasonable and necessary
in this case. Our physician reviewer found clinical practice guidelines form the American Urological
Association (AUA)/American Society for Radiation Oncology (ASTRO)/Society of Urologic Oncology
(SUO)/American Society of Clinical Oncology (ASCO) conclude that proton beam therapy offers no clinical
advantage over other forms of definitive treatment. The National Comprehensive Cancer Network (NCCN)
Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either
treatment efficacy or long-term toxicity, but it is associated with significantly increased cost. The service 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 Proton treatment delivery; complex (77525) have not been met. Therefore, we
decided that the Plan does not have to pre-approve Proton Beam Radiation Therapy (PBRT).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromonitoring services (95861, 95865, 95868, 95938, 95939, 95955) provided on August 5, 2019.
You asked the Plan to pay for neuromonitoring services. You say that these services should be covered. The Plan denied your request. The Plan says these services were billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity. We looked at the file and Medicare rules. The services at issue were billed with POS 15 for a mobile unit, but the records show that they were performed in service of an entity, in this case a hospital, for which a different POS exists. Based on this information, we decided that Medicare rules for coverage of neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95861, 95865, 95868, 95938, 95939, 95955) provided on August 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin.
You asked the Plan to pre-approve Oxycontin. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested drug is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin.
Benefits for Oxycontin may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the paramedic intercept services provided on September 23, 2020.
You asked the Plan to pay for the paramedic intercept services. You say that this service was lifesaving and necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The rules say that Medicare pays for advanced life support (ALS), in accordance with state and local laws by an emergency medical technician (EMT) intermediate or EMT-Paramedic only in certain circumstances. Medicare allows ALS paramedic intercept services only when the services are furnished in a rural area as defined above. It is noted that the only State in which these criteria are met is New York. The paramedic intercept services at issue in this appeal were not furnished in an area that is considered rural according to the Medicare definition. Therefore, we decided that the Plan does not have to pay for the paramedic intercept services provided on September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on October 21, 2020.
You asked the Plan to pay for subsequent hospital care (99233). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this service is part of the anesthesia care package billed under code 00670 rendered by a different practitioner.
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, we have confirmed that code subsequent hospital care 99233 has a bundled relationship with code 00670 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for subsequent hospital care provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab testing (81405, 81406, 81407, 81408, 81479) provided July 11, 2020.
You asked the Plan to pay for the lab testing. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The plan documentation shows there is no history of the ordering physician providing any evaluation and management services for the enrollee. Based on this information, we decided that Medicare rules for coverage of the lab testing have not been met. Therefore, we decided that the Plan does not have to pay for lab testing (81405, 81406, 81407, 81408, 81479) provided July 11, 2020.