Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine (72141).
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 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 MRI. Our reviewer says that the MRI is not medically necessary. Our physician reviewer found there are no abnormal physical exam findings, no previous cervical spine films, or lab studies. There is no documentation of attempted treatments such as home exercise, physical therapy, or medications. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve Magnetic Resonance Imaging (MRI) of the cervical spine (72141).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from May 10, 2019 to
September 13, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis
while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider,
which requires prior authorization from the plan.
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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided from May 10, 2019 to September
13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of home ventilator, any type, used with non-invasive interface, (E0466).
You asked the Plan to pre-approve the ventilator. You say that your pulmonary specialist, nurse and the supplier suggests this item to assist with breathing correctly without issues because your lungs are in bad condition. The Plan denied your request. The Plan says the enrollee does not meet the criteria. The plan has instead approved a different machine called a (CPAP) continuous positive airway pressure device that helps with breathing while you sleep.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have COPD. There is no evidence that the enrollee has a neuromuscular disorder or thoracic restrictive disease. The enrollee had had a home ventilator in the past, but has been non-compliant with use. The enrollee was recently noted to have stopped using the home ventilator all together. The documentation does not support that the use of a home ventilator is medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of home ventilator, any type, used with non-invasive interface, (E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided on July 24, 2019.
You asked the Plan to waive the copayment for the outpatient surgical services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a procedure in an outpatient hospital facility that is considered a surgical procedure per Medicare guidelines on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $400 copayment for Medicare-covered outpatient hospital surgery services. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a procedure at an outpatient hospital facility that is considered a surgical procedure on July 24, 2019. You have been asked to pay a $256.83 copayment for the outpatient surgical services, which is less than the contracted $400 copayment amount. The outpatient surgical services fall within the Outpatient hospital services 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 surgical services provided on July 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 95909 and 95886 provided on November 30, 2019.
You asked the Plan to pay for CPT codes 95909 and 95886. You say that the medical records support the billing of CPT codes 95909 and 95886. The Plan denied your request. The Plan says the medical records do not support the billing of CPT codes 95909 and 95886.
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 95909 is Nerve conduction studies; 5-6 studies. The definition of code 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (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 CPT codes 95909 and 95886. Our reviewer says that the medical records do not support the billing of CPT codes 95909 and 95886. Our physician reviewer found CPT code 95909 does not meet criteria for billing or reimbursement consideration. The technical report in the medical records provided does not include documentation on a nerve conduction studies; for 5-6 studies, therefore this service cannot be validated as being performed on November 30, 2019. The use of pedicle screws, as noted in the medical record, does not meet definition criteria for CPT code 95909. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. CPT code 95886 does not meet criteria for billing or reimbursement consideration. CPT code 95886 is an add-on code. Medicare states that "An add-on code is eligible for payment if and only if one of its primary codes is also eligible for payment." In this case, CPT code 95909, the primary service code was denied by the health
plan therefore, CPT 95886 is not eligible for separate reimbursement. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT codes 95909 and 95886 have not been met. Therefore, we decided that the Plan does not have to pay for CPT codes 95909 and 95886 provided on November 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the medical eye exam provided on November 22, 2019.
You asked the Plan to waive the coinsurance for the medical eye exam. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says that you pay 50% for these services.
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% coinsurance for Medicare covered eye exams to diagnose and treat diseases and conditions of the eye provided out-of-network. You have been asked to pay a 50% coinsurance for the medical eye exam. The medical eye exam falls within the Medicare covered eye exam to diagnose and treat diseases and conditions of the eye provided out-of-network 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 the medical eye exam provided on November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan of the abdomen and pelvis. Our reviewer says that the service is not medically necessary. Our physician reviewer found in this enrollee's case there is a plan for a (carcinoembryonic antigen) CEA draw and surveillance colonoscopy; neither has been done yet. While CT of the abdomen and pelvis for Stage I colon cancer has not been established as a medical necessity that may change pending the enrollee's planned colonoscopy and CEA level determination. 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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis (74177).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the apicoectomy (D3425) provided on January 22, 2020.
You asked the Plan to pay for the apicoectomy. You say that you were notified on December 28, 2019 by the Plan that this procedure was approved. You also say that there should be no reason to deny this claim because the service was pre-approved, and the infection occurred in 2019. The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.
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. The Plan says that claims will be processed based on when the services are received from the provider for that date of service according to that Plan's benefits. Receiving a prior authorization for procedures does not guarantee that the Plan will pay for the service(s), payment will be subject to the Plan's benefit coverage. Therefore, we decided that the Plan does not have to pay for the apicoectomy (D3425) provided on January 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider October 16, 2019 and October 18, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) rendered by the out of network (OON) provider October 16, 2019 and October 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (70551, 70544) provided
on September 13, 2019.
You asked the Plan to pay for the Magnetic Resonance Imaging. You say that the services were medically
necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There
were network providers available.
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 has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the Magnetic Resonance Imaging (70551, 70544) provided on September 13,
2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on February 13, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that your gums were hurting which is why you went to the dentist. You also say that the provider did not inform you that this service was not covered by your insurance plan. The Plan denied your request. The Plan says this service is a non-covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The Plan contract clearly states that periodic and comprehensive exams are the only exams covered by your plan. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on February 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided October 20, 2019 to October
24, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically
necessary. The Plan denied your request. The Plan says that care could have been rendered in an outpatient
setting.
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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record shows that at the time of admission the attending physician reasonably expected that
care would span at least two 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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided October 20, 2019 to October 24, 2019.
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 pre-approve the pillow wedge (A9270).
You asked the Plan to pre-approve the pillow wedge. You say that you need the wedge pillow that goes underneath your mattress so you can lay at an angle to which you can breathe easier and not have your stomach contents and bile come up into your mouth. The Plan denied your request. The Plan says this item is not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the pillow wedge (A9270).
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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous Spacer procedure (22869, 22870).
You asked the Plan to pre-approve a Vertiflex Superion Interspinous Spacer procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 Superion Interspinous Spacer procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion Interspinous Spacer procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous Spacer procedure (22869, 22870).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stays provided from
September 21, 2019 to October 19, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stays. You say that you are being billed
for both inpatient stays. You say you were told that being re-hospitalized within 4-6 days for the same reason
would still be considered the same inpatient stay. The Plan denied your request. The Plan says you have been
charged 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 $345
copayment for each day for days 1 to 5 for Medicare-covered hospital care and a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a $345 copayment for each day, for days 1 to 5 for each of the inpatient hospital
stays. ($345 x 5 = $1,725) ($1,725 x 2 = $3,450). The inpatient hospital stay falls within the "Inpatient hospital
care" 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 inpatient hospital stays provided from September 21,
2019 to October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99190 provided on December 11, 2019.
You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we decided that the Plan does not have to pay for CPT code 99190 provided on December 11, 2019.