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

We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer placement for the enrollee.
You asked the Plan to pre-approve the placement. You say that this is medically necessary, as the enrollee is not a candidate for surgical decompression and fusion. The Plan denied your request. The Plan says Medicare has only covered this service in the context of a clinical trial.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the spacer remains experimental at this time. More research is needed to show safety and effcacy. 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 placement have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer placement for the enrollee.
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 the services are 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical status does not require intensive physician or nursing oversight in an IRF. You may benefit from additional multiple therapies, however your decreased endurance does not require or indicate that this therapy must be in an IRF with an intensive level program. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe ambulance transport provided on December 27, 2019.You asked the Plan to waive the copay forthe ambulance transport. You say that the enrolleeshould not be responsible for this because shecould have been taken in the car.The Plan denied your request. The Plan says that the claim processed 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 $285 copay for each covered, one-way ambulance trip by ground or water. The enrollee hasbeen asked to pay a $285 copay for the ambulance transport. The ambulance transport falls within the one-way ambulance trip by ground or water benefit category. This means that the enrollee hasbeen asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation the enrolleeagreed to pay when sheenrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copay forthe ambulance transport provided on December 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional mileage for yourroutine transportation.You asked the Plan to pre-approveadditional miles. You say that you need to have a follow-up visit with your eye surgeon.The Plan denied your request. The Plan says your benefit only allows 50 miles.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. Transportation over 50 miles was requested. We looked at your request, the records in the case file, and the rules. Your plan only covers transportation for up to 50 miles per one-way trip. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approveadditional mileage for your routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 8, 2020.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 on January 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291)and hemodialysis services (90935) provided on October 30, 2019 through October 31, 2019.You asked the Plan to pay for the critical care and hemodialysis services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the billed services.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 99291 and 90935 is not supported in the record. Specifically, the record does not indicate that the billed services were rendered on the billed dates of service. The documentation submitted reflects a different date of service than what was billed. Based on this information, we decided that Medicare rules for coverage of the critical care and hemodialysis services have not been met.Therefore, we decided that the Plan does not have to pay for critical care services (99291) and hemodialysis services (90935) provided on October 30, 2019 through October 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants.
You asked the Plan to pre-approve dental implants. The Plan denied your request. The Plan says the dental service is not covered by Medicare or your 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. Although the Plan offers a dental benefit in excess of Medicare coverage, the requested implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe oral exam (D0120) and prophylaxis (D1110) provided on January 16, 2020 by out of network provider.You asked the Plan to reimburse you forthe dental services. You say that the description of plan benefits under preventive dental services states there is a "$0 copay for exams, cleanings, x-rays, and fluoride". You say that this applies to both in network and out of network dentists. You also say that you should be reimbursed the $147.35 that you were charged.The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says that the cost share amount was applied correctly as you were charged for the difference of thecharged amount and the allowed amount.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 adental benefit in excess of Medicare coverage and the oral exam and prophylaxis are listed as covered, dental services that you receive out of network are paid according to a maximum allowable fee schedule and you are responsible for all fees in excess ofthis amount from the billed amount. Additionally, cost sharing  is a contractual obligation of the plan and  cannot be waived.Therefore, we decided that the Plan does not have to reimburse you forthe oral exam (D0120) and prophylaxis (D1110) provided on January 16, 2020 by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 13, 2019.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a necessary service. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 25, 2019.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that you need a portable oxygen concentrator for sleeping while away from home. The Plan denied your request. The Plan says only rented oxygen equipment is eligible for coverage.
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Medicare only covers oxygen for in home needs. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNFcare. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs are met in her current long term care setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the enrollee has no identifiable skilled therapy needs, and while she has skilled nursing needs, she does not need skilled care on a daily basis. She also does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 7, 2020 to February 21, 2020 by an out of network (OON) provider.You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration because you have a history with this provider and there is a waiting list for other providers that offer the necessary services.The Plan denied your request. The Plan says this provider is not accepted by Medicare.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. Additionally, this provider is not eligible to bill Medicare. The Plan has network providers available who can provide 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 medical services provided on February 7, 2020 to February 21, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair and a grab bar.You asked the Plan to pre-approvea shower chair and a grab bar. You say that you would like the Plan to reconsider providing coverage for the requested shower chair and shower grab bar. You say that your primary care physician recommended these items for you. You stated that you have fallen fifteen times in one monthand had to go to urgent care three times because of it.The Plan denied your request. The Plan says these items are not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that shower chairs and grab bars are not covered because they are not primarily medical in nature. While a shower chair and a grab bar 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-approvea shower chairand a grab bar.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve back surgery (laminectomy, facetectomy, and foraminotomy).
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is a discrepancy between the radiologist's interpretation of the MRI and the doctor.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show severe spinal stenosis. The MRI's official read does not show severe canal stenosis. The surgery is not needed, and the criteria is not met. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve back surgery (laminectomy, facetectomy, and foraminotomy).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician services rendered on January 23, 2020.
You asked the Plan to waive the deductible for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the deductible was applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $1,000 yearly deductible for your covered medical services. The item or service you asked the Plan to waive the deductible for falls within the physician services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $1,000 yearly deductible for your covered medical services. This cost sharing is a contractual obligation that had not been met at the time these services were received on January 23, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the physician services rendered on January 23, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric hospital services
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are medically necessary. The Plan denied your request. The Plan says that rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the requested services are medically necessary. Our physician reviewer found the record shows the enrollee has suicidal ideation and hallucinations. The enrollee's condition warrants an inpatient level of 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 inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric hospital services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 19, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on December 19, 2019. The allowed amount is $1,179.69 and 20% of that is $235.94. You have been asked to pay the total coinsurance amount of $235.94 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on December 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on February 12, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that this was a follow-up visit and you 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 $35 copayment for each specialist visit. You had a specialist visit on February 12, 2020. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 97535 provided from January 1, 2020 to January 10, 2020.
You asked the Plan to pay for CPT code 97535. 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. The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. The medical records provided do not show that the services billed with the -59 modifier are distinct procedural services. Specifically, CPT code 97535 is a column 2 component of column 1 CPT code 97530. A modifier is allowed to unbundle these codes; however, the documentation should clearly show that these procedures were distinct and independent to one another. In this case, the documentation shows the total time for all timed therapy codes; however, there are no activities or modalities listed for each timed therapy procedure to determine if the codes are distinct and independent to one another. Therefore, we decided that the Plan does not have to pay for CPT code 97535 provided from January 1, 2020 to January 10, 2020.