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

We decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen system.

You asked the Plan to pre-approve an oxygen concentrator and portable oxygen system. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says the documentation does not indicate the coverage criteria have been met.

The Plan must follow Medicare rules. The rules say that for patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90%, there is a rebuttable presumption of non-coverage for home oxygen. 

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 an oxygen concentrator and portable oxygen system. Our reviewer says that the medical records do not support the medical necessity of home oxygen. Our physician reviewer found this patient has a previous cervical spine injury resulting in restrictive lung disease and obstructive sleep apnea. He uses CPAP day and night without a strap, with O2 bled in at 15 L/min. The medical records do not show any arterial blood gases or PO2 measurements off of oxygen, or that they meet Medicare criteria for oxygen need (<89%). 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oxygen concentrator and portable oxygen system have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator and portable oxygen system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.

You asked the Plan to pre-approve incontinence supplies. You say that you were receiving incontinence pad help while you were in a facility. When you were moved, the pads continued to be delivered without being sent to you for your use. You still cannot get around and have incontinence problems. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. 

While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary for chronic pain. The Plan denied your request. The Plan says a trial implantation is appropriate before a permanent procedure is done.
The Plan must follow Medicare rules. Medicare rules say that a trial is needed before permanent placement of a stimulator. 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 stimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the last trial for a stimulator was in 2014 and was not successful. Another adequate trial is needed prior to permanent placement of the stimulator. 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit (99214) provided on
May 4, 2021.

You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for provider and professional services rendered at a specialist's office.

You have been asked to pay $16.22 ($81.08 x 20% coinsurance) for the specialist office visit provided. 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 office visit (99214) provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740 x2).
You asked the Plan to pre-approve crowns. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the teeth meet criteria for approval.
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 crowns when the services are medically necessary and reasonable. 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 crowns. Our reviewer says that criteria have not been met, and there is no necessity for the services at issue. Our physician reviewer found the documentation provided does not show significant coronal breakdown due to caries or fracture to meet the criteria for coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crowns have not been met. Specifically, coverage criteria were not met for the service at issue. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on June 11, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the services are available within the network.

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 had network providers available who could have provided the dermatology 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 dermatology services provided on June 11, 2020 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 3, 2020 to August 14, 2020.
You asked the Plan to pay for home health services. 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 as billed.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim is missing an appropriate G code per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 3, 2020 to August 14, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for an ER visit provided on June 4, 2020.
You asked the Plan to waive the copayment for an ER visit. You say that you were admitted inpatient within 24 hours of the ER visit and should not owe a copayment. The Plan denied your request. The Plan says that the claims were processed correctly and you are being charged the correct amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide medical records within the original case file that substantiated their decision. Furthermore, without medical records we cannot determine whether or not an inpatient hospital admission occurred within 24 hours of the ER visit. Therefore, we decided that the Plan has to waive the copayment for an ER visit provided on June 4, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on June 16, 2020.

You asked the Plan to pay for code 97530. 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 as 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 code 97530 is not supported in the medical record. Specifically, the records indicate that the services were performed by an occupational therapist assistant in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the Plan does not have to pay for the therapy services represented by code 97530 provided on June 16, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.

You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the administration and vaccine provided on April 15, 2021.

You asked the Plan to pay for Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) and administration (90471). You say that you did not know the vaccine would not be covered if administered by your physician. The Plan denied your request. The Plan says vaccines are covered under Medicare Part B when necessary to treat an injury or illness.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) and administration (90471). The Plan follows the same rules.

Records do not show that you have been injured or directly exposed to any illness related to Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap) (90715) and administration (90471). Therefore, we decided that the Plan does not have to pay for the administration and vaccine provided on April 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided on January 27, 2021, and January 28, 2021.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you received the services at home and should not owe a copayment. 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 $40 copayment for outpatient rehabilitation services. The record shows that you received outpatient rehabilitation services on January 27, 2021, and January 28, 2021. Therefore, you are responsible to pay a $40 copayment per each service. The total amount you owe is: $80. You have been asked to pay the total copayment amount of $80 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided on January 27, 2021, and January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided March 4, 2021.

You asked the Plan to pay for the comprehensive oral exam and complete series of x-rays. You say that a comprehensive exam is necessary for new patients and you do not understand why it is not covered. The Plan denied your request. The Plan says the x-rays are not a covered service and you have exceeded frequency limits for the comprehensive exam.

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 the comprehensive oral exam once every three calendar years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive exam was previously covered on February 17, 2020. Based on this information, we determined that the Plan's frequency limits for the comprehensive oral exam has been exceeded. Though the Plan offers dental benefits in excess of Medicare coverage, the intraoral x-rays are not among those services covered. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established patient (D0150) and intraoral - complete series of radiographic images (D0210) provided March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a diagnostic endoscopy (31231).
You asked the Plan to pre-approve the diagnostic endoscopy. You say that the procedure is medically necessary. The Plan denied your request. The Plan says 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 the diagnostic endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested endoscopy is to be performed with a procedure. CPT code 31231 is defined as a diagnostic procedure whereby an endoscope is inserted into the nasal cavity to examine the structures of the nasal cavity on one or both sides. No procedure is performed simultaneously.
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 diagnostic endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic endoscopy (31231).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care rendered on December 11, 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 the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 99309 is 1. You billed 2 units of this code, exceeding the MUE. 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 subsequent nursing facility care rendered on December 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device.

You asked the Plan to pre-approve the Vertiflex device. The Plan denied your request. The Plan says this 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 the Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer-reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4/5 is not medically reasonable or 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and the limited oral evaluation - problem focused (D0140) received March 10, 2021 from the out-of-network provider.
You asked the Plan to pay for the intraoral radiographic image and limited oral evaluation. You say that you cannot afford the cost of these services. The Plan denied your request. The Plan says when services are performed by a non-participating provider, you are responsible for any difference between the Plan's Maximum Allowable Fee and the amount the out-of-network provider bills you for the services.
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, limited oral evaluations - problem focused (D0140) is not among those covered under this benefit. The Plan provides coverage for intraoral - periapical radiographic images. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider. The Plan agreed to pay 100% of the allowed amount for the intraoral radiographic image. You are responsible for the difference between the Plan's allowed amount and what was charged by the out-of-network provider. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image (D0220) and the limited oral evaluation - problem focused (D0140) received March 10, 2021 from the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pain management office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the pain management office visit. You say that you are appealing the denied claim. The Plan denied your request. The Plan says the provider is out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the pain management office visit to be provided by an out of network (OON) provider.