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

We decided that the Plan does not have to pay for the oxygen concentrator and stationary compressed gaseous 
oxygen system provided from June 10, 2020 to October 31, 2020 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the oxygen concentrator and stationary compressed gaseous oxygen system. You 
say that you are willing to pay your copayment for these items. You also say that you wanted the device that 
you knew was new and not used. The Plan denied your request. The Plan says the items received are not a 
covered benefit. 
 
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. 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 oxygen concentrator and stationary 
compressed gaseous oxygen system provided from June 10, 2020 to October 31, 2020 by an out-of-network 
(OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex device.
You asked the Plan to pre-approve 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 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 chronic lumbar pain and spinal stenosis with neurogenic claudication. The record indicates that recent imaging has demonstrated greater than moderate spinal stenosis at L4-L5, the level requested for treatment. Previous imaging reports severe spinal stenosis at this level. The enrollee is at risk for osteoporosis and record does not indicate that the enrollee has been evaluated for osteoporosis. The elements of the coverage criteria are not satisfied.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you are experiencing a lot of pain and it is harder for you to walk. The Plan denied your request. The Plan says this item is 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 foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on March 29 through April 14, 2021.
You asked the Plan to pay for the SNF services. You say that your attending physician stated that you needed SNF care when the Plan's denial was issued. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says the enrollee's care could be safely managed in the home setting with intermittent home health care therapy services. 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. During the period of care from March 29 through April 14, 2021, the enrollee did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care from March 29 through April 14, 2021. She did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved; however, her function had plateaued she did not require any further inpatient skilled rehab services. The enrollee's function was at or near her new baseline level of function and she could be discharged to a lower level of care for further services. She required custodial 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided on March 29 through April 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee has tried and failed conservative treatment and physical therapy is not recommended. The Plan denied your request. The Plan says the denial of authorization for inpatient level of care is correct, because this has been approved as an ambulatory procedure.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee is medically stable and has been provided clearance to undergo elective reverse shoulder arthroplasty as an ambulatory procedure. The record does not show that the admitting physician would reasonably expect that the enrollee's necessary hospital care will span at least 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve radiofrequency ablation. 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 follows Medicare rules. Medicare rules say that if there is an extended time, two years or more, since the last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedures must be repeated. 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 radiofrequency ablation. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have chronic axial low back pain. You currently take Norco for pain. You have had a trial of physical therapy without improvement. You underwent radiofrequency ablation in June 2018. The pain has returned after two years. The LCD requires repeat diagnostic medial branch blocks since it has been greater than two years since the radiofrequency ablation. Therefore, you do no 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to 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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on December 22, 2020.
You asked the Plan to pay for the laboratory testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice. 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 date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus testing (U0003) provided on December 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
You asked the Plan to pre-approve the 60 additional routine transportation trips. You say that you need transportation to medical appointments and have no other options. The Plan denied your request. The Plan says your request exceeds the benefit limitation of 60 one-way trips per calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way routine transportation trips per year. We looked at your request, the records in the case file, and the rules. The records show that, at the time of your
request, you had used 58 one-way routine transportation trips in the 2021 calendar year. Based on this information, we decided that the number of additional trips being requested would exhaust the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 60 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 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 the Vertiflex procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on February 5, 
2021. 
 
You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges 
because the laboratory services were part of your annual physical exam. 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 $10 
copayment for laboratory services.  
 
You have been asked to pay a $10 copayment for laboratory services. 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 February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide routine transportation trips.
You asked the Plan to provide routine transportation services. You say that the enrollee needs transportation to hemodialysis and is unable to navigate the public transportation system. The Plan denied your request. The Plan says the enrollee's benefit plan does not include a routine transportation benefit.
The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of routine transportation trips have not been met. Therefore, we decided that the Plan does not have to provide routine transportation trips.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.

You asked the Plan to pre-approve routine transportation. You say that you have had to cancel numerous appointments for significant health issues due to lack of transportation. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 24 one-way trips per calendar year is not covered by the Plan.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
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 care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that, based on the documentation provided, you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures coded 97110 and 97116 provided on June 19, 2020.
You asked the Plan to pay for the therapeutic procedures. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 97110 and 97116 are not supported in the medical record. Specifically, the documentation shows that these services were provided by a physical therapy assistant. The documentation does not support that a physical therapist was physically present. There are more appropriate codes to be billed for services when provided by a physical therapy assistant. Based on this information, we decided that
Medicare rules for coverage of the therapeutic procedures have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures coded 97110 and 97116 provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam, bitewing x-rays, composite filling, crown and core buildup, and unlisted procedure rendered on January 12, 2021.
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 services from a non-participating 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. The Plan covers supplemental dental benefits from a participating provider only.
We looked at this the file and the Plan's rules. The file shows that you received services from a non-participating provider. Based on this information, we decided that the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the limited oral exam, bitewing x-rays, composite filling, crown and core buildup, and unlisted procedure rendered on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95908, 95885, 95999) provided on December 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 95908 is "Nerve conduction studies; 3-4 studies". 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 CPT Code Manual Definition of code 95999 is "Unlisted neurological or neuromuscular diagnostic procedure".
We asked our coding 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 the services. Our reviewer says that the use of codes 95908, 95885, and 95999 is not supported by the records provided. Our coding reviewer found that for code 95908, the technical report did not include documentation showing 3-4 nerve conduction studies were performed. For code 95885, the technical report does not document a needle EMG was performed with nerve conduction study. For CPT 95999, the documentation did not include documentation required per Medicare for the use of an unlisted code. We looked at this coder's review, the file, and Medicare rules. 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 the services (95908, 95885, 95999) provided on December 10, 2020.