Persius/hicric huggingface dataset:
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 a skilled nursing facility is not the appropriate level of care at this time. The Plan denied your request. The Plan says the enrollee does not require specialized nursing services that are only available in an LTACH.
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 physician reviewer found that in this case, the enrollee was admitted with a bowel obstruction and underwent surgery. Her course was complicated by intraabdominal infection. The record indicates that she will be transferred to a skilled nursing facility to complete antibiotic therapy. The enrollee continues to receive acute care services that have not been denied. The medical records provided do not indicate that the enrollee requires acute care services that she is not currently receiving that would be available at the LTACH. Therefore, the requested services are not 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this treatment is considered safe and effective, and the enrollee is a good candidate for it. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex 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 Vertiflex. 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 is experimental. More research is needed to show the safety and efficacy 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 Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block (64454) and a genicular nerve radiofrequency ablation (64624).

You asked the Plan to pre-approve a genicular nerve block and a genicular nerve radiofrequency ablation. You say that the requested procedures are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for the requested procedures have not been met.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 64454 and 64624 are only covered for specific conditions. 

We looked at the file and Medicare rules. The case record indicates that the requested procedures have been requested for treatment of ICD-10 code M17.0, Bilateral primary osteoarthritis of knee. Code M17.0 is not cited in the Medicare rules list of codes that support medical necessity for the requested procedures. Based on this information, we decided that Medicare rules for coverage of a genicular nerve block and a genicular nerve radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64454) and a genicular nerve radiofrequency ablation (64624).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand finger orthosis (L3809) provided on January 28, 2021.
You asked the Plan to pay for the wrist hand finger orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not include a written order, proof of delivery or physician's note to indicate medical necessity.
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 physician order or proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Additionally, the documentation submitted indicates that the member received this equipment in 2018. The billed orthosis is prior to the reasonable useful lifetime limit. Therefore, we decided that the Plan does not have to pay for the wrist hand finger orthosis (L3809) provided on January 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that the enrollee needs physical therapy to stay mobile. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or therapy care.
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. Continued SNF services beyond June 10, 2021, were requested. 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 continued services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a contact guard to minimal assist level with functional mobility. He required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. He does not require skilled nursing or therapy services on a daily basis. He does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a NeuroStim system for auricular peripheral nerve stimulation.

You asked the Plan to pre-approve a NeuroStim. You say that the enrollee is likely to obtain significant therapeutic benefit from the neurostimulator treatment. The Plan denied your request. The Plan says the requested item/service is not a Medicare benefit.

The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulation is non-covered. 

We looked at the file and Medicare rules. NeuroStim is a device for auricular peripheral nerve stimulation. Based on this information, we decided that Medicare rules for coverage of a NeuroStim have not been met. Therefore, we decided that the Plan does not have to pre-approve a NeuroStim system for auricular peripheral nerve stimulation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power scooter (incorrectly coded as CPT code E1399).
You asked the Plan to pre-approve the power scooter. You say that you are unable to get around and need this to be able to have mobility. The Plan denied your request. The Plan says Medicare requires specific evaluations be done prior to approval of the device you are requesting. The Plan states you have not completed the necessary evaluations for approval of this device.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power scooter have not been met. You are able to use a walker in the home and want the scooter for outside. There is also no home evaluation or order in the records received. Therefore, we decided that the Plan does not have to pre-approve the power scooter (incorrectly coded as CPT code E1399).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 6, 2020.

You asked the Plan to pay for the lab services. You say that payment was made for the same test last year. The Plan denied your request. The Plan says the testing was ordered by a naturopathic provider.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

We looked at the file and the rules. The records provided do not show that the testing was ordered for a specific
diagnosis or treatment plan. The testing was requested for screening purposes. Also, naturopathic services are
not covered under any condition. Therefore, we decided that the Plan does not have to pay for the lab services
provided on November 6, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on May 20, 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 procedure code 97530 is not supported.
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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the
services were performed in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on May 20, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says care can be provided safely at a less intensive setting of care, such as skilled nursing facility.
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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
weakness and back pain and had lumbar spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do 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. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction and five resin-based composites provided on
February 12, 2021, and February 23, 2021.
You asked the Plan to pay for the extraction and resin-based composites. You say that you do not agree with
how these claims were processed. The Plan denied your request. The Plan says these claims were processed
correctly, and the $89.45 coinsurance is your contractual responsibility.
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, you are responsible for a 20%
coinsurance for restorative services and extractions. Therefore, we decided that the Plan does not have to pay
for the extraction and five resin-based composites provided on February 12, 2021, and February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0482) provided to the
enrollee on July 9, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says Healthcare Common Procedure Coding System (HCPCS) code G0482 (1 Unit) remains not
supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that HCPCS code G0482 is not supported in the medical record. Specifically, the place of service on
the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects
a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's
office (POS 11) Based on this information, we decided that Medicare rules for coverage of the services have
not been met. Therefore, we decided that the Plan does not have to pay for drug testing services (HCPCS
G0482) provided to the enrollee on July 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on
November 14, 2019.

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The
Plan denied your request. The Plan says the copayment was 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 $75
copayment per day for outpatient procedures and services performed in an outpatient hospital or ambulatory
surgical center.

Review of the file shows that you received a diagnostic colonoscopy on November 14, 2019. You have been asked to pay a $75 copayment for these services. These services fall within the outpatient procedures and services performed in an outpatient hospital or ambulatory surgical center 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 outpatient hospital services rendered on November 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bavencio for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is in a clinical trial.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Bavencio for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (bilat L3-L4) (64635), Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (bilat L4-L5 and L5-S1) (64636) and Moderate sedation services (99153) 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 radiofrequency ablation of the nerves innervating these facet joints is not reasonable or necessary at this time.
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 requested services are not considered medically reasonable and necessary in this case. The LCD requires dual sets of diagnostic MBBs which produces 80% pain relief. This is not documented on the first set and a second set has not been performed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of 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 Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (bilat L3-L4) (64635), Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (bilat L4-L5 and L5-S1) (64636) and Moderate sedation services (99153) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided August 31, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services billed.
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 code 97530 is not supported in the medical record. Specifically, the record shows that the services were provided in the home health setting. There is a more appropriate CPT code for the services billed (G0158). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97530) provided August 31, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) rendered on
November 25, 2020.
You asked the Plan to waive the copayment for these services. You say that you didn't ask for the EKG and
agreed without knowing there would be a copayment. The Plan denied your request. The Plan says the
copayment was 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 $10
copayment per day for Medicare-covered tests, including EKG.
Review of the file shows that you received an EKG on November 25, 2020. You have been asked to pay a $10
copayment for these services. These services fall within the Medicare-covered tests, including EKG 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 electrocardiogram (EKG) rendered on
November 25, 2020.