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

We decided that the Plan does not have to pay for transportation of portable x-ray equipment (R0070) provided February 7, 2020.You asked the Plan to pay for the transportation of portable x-ray equipment. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim was filed incorrectly.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 R0070 is not supported in the medical record. Specifically, CPT code R0700 has a Professional Component (PC) / TechnicalComponent (TC) indicator of 3 per the January 2020 National Physician Fee Schedule. The code was billed with an improper place of service. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment have not been met.Therefore, we decided that the Plan does not have to pay fortransportation of portablex-ray equipment (R0070) provided February 7, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on February 21,
2020.
You asked the Plan to waive the copayment for the CT scan. You say that this should be covered under the
observation copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275
copayment for each advanced imaging service.
You have been asked to pay a $275 copayment for the CT scan. The CT scan falls within the "Outpatient
hospital observation" benefit category. Services are charged separately while in outpatient observation. 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 CT scan provided on February 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee. You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental and 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 the device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with lumbar radicular pain and a diagnosis of lumbar spinal stenosis with neurogenic claudication. Conservative treatment has included activity modification, medications, epidural steroid injections and physical therapy. There is imaging evidence of severe central canal stenosis at L4/5 with grade 2 anterolisthesis and severe neuroforaminal stenosis, and moderate to severe left neuroforaminal stenosis at L5/S1. Under consideration is a request for the Vertiflex Superior device at two levels. 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. FDA criteria for the use of the Vertiflex Superion device have not been met. FDA indications include implantation of the Superion device for the treatment of moderate spinal stenosis. This enrollee has severe stenosis at the L4/5 level and moderate to severe stenosis at the L5/S1 level. There is no rationale why standard surgical decompression would not be indicated. Additionally, FDA contraindications include spinal instability with spondylolisthesis greater than grade 1. This enrollee has grade 2 spondylolisthesis at the L4/5 level. There is also no discussion of past medical history or comorbidities that would exclude osteoporosis and morbid obesity. Therefore, this request for Vertiflex Superior device implantation (CPT codes 22869 and 22870) is not reasonable and medically necessary for this enrollee's medical 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar/interspinous process stabilization/distraction device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the skin surgery provided on November
18, 2019. You asked the Plan to reduce the coinsurance for the skin surgery. You say that you were not aware the
provider was out-of-network. You say you would like the claim processed as in-network. 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 50% of
the Medicare-allowed amount at an out-of-network outpatient hospital facility.
You have been asked to pay $789.83 which is 50% of the allowed amount for the skin surgery. The allowed
amount is $$1,579.66. ($1,579.66 x 50% = $789.83). The skin surgery falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.
The record shows the provider is out-of-network.
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 reduce the coinsurance for the skin surgery provided by on November 18, 2019.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be received in a different 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is mobile with limited supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower level of care (ex. intermittent therapy, nursing therapy). 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 admission 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve rotator cuff repair.
You asked the Plan to pre-approve the requested services. You say that this is a recurrent retracted tear. The Plan denied your request. The Plan says that there are more conservative treatments available that have not been attempted.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 requested services. Our physician reviewer found that the enrollee presents with worsening right shoulder pain with associated weakness. Functional difficulty is noted in activities of daily living. She is status post right shoulder rotator cuff repair in July 2018. Clinical exam findings are consistent with imaging evidence of a recurrent retracted supraspinatus tendon tear and partial thickness subscapularis tear. Under consideration is a request for revision right shoulder arthroscopic rotator cuff repair. Current evidence based medical literature would support proceeding with surgery despite limited conservative treatment. There is no significant loss of range of motion or strength deficits that would support the medical necessity of pre-operative physical therapy. A corticosteroid injection is not supported in current evidence based medical literature in this enrollee's clinical scenario. Therefore, this request for revision right shoulder arthroscopy with rotator cuff repair is medically reasonable and 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve rotator cuff repair.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have topre-approveProlia 60 mg/ml syringe (J0897).You asked the Plan to pre-approveProlia 60 mg/ml syringe. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteriahas not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Prolia 60 mg/ml syringe. Our reviewer says that the medication is not necessary. Our physician reviewer found the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia 60 mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia 60 mg/ml syringe (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injections provided on October 1, 2019 and October 17, 2019.You asked the Plan to waive the coinsurance forthe Part B injections. You say that you received authorization for the injections and you were told that insurance should cover the medication. 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 20% coinsurance for all other drugs covered under Medicare Part B. You have been asked to pay $700 which is 20% of the allowed amount for the Part B injections on each date of service. The Part B injections fall within the "Medicare Part B prescription drug" 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 forthe Part B injections provided on October 1, 2019 and October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forpathology services provided on February 10, 2020.You asked the Plan to pay forthe services provided. You say that the pathology report provides evidence of medical necessity.The Plan denied your request. The Plan says the testing is not a Medicare benefit for the diagnoses listed.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes.Therefore, we decided that the Plan does not have to pay forpathology services provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the knee injection provided on February 12, 2020.You asked the Plan to waive the copayment for the knee injection. You say that the knee injection was not surgery. You say you already paid your office visit copayment and you should not be charged this amount. 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 $250 per visit, per provider, per day for surgery performed in an outpatient hospital setting. You have been asked to pay a $250 for the knee injection. The knee injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient hospital facility. The record also shows that the knee injection is considered a surgical procedure.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 forthe knee injection provided on February 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the CPAP device (CPT Code E0601RR) provided on April 11, 2020 by an in-network provider. You asked the Plan to waive the coinsurance for the DME. You say that you thought Medicare would pay all CPAP costs. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020
EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Review of the file show that you received the CPAP device on April 11, 2020 by an in-network provider. You are asked to pay 20% coinsurance for the DME. Your EOC states, enrollees must pay 20% coinsurance for in-network DME and related supplies. 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 CPAP device (CPT Code E0601RR) provided on April 11, 2020 by an in-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that The Plan does not have to pre-approve a Core Build-Up (D2950). You asked The Plan to pre-approve Core Build-up. You say that the services are medically necessary.The Plan denied your request. The Plan says while covered benefits, the requested services are not medically indicated at this time.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. Core build-up is not listed as a covered benefit in the Plan's dental handbook.We looked at the file and Medicare rules.Core Build-Up is not a covered benefit.Based on this information, we decided that the Plan's rules for coverage of Core Build-up have not been met.Therefore, we decided that The Plan does not have to pre-approve a Core Build-Up (D2950).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ubrelvy Tab.
You asked the Plan to pre-approve Ubrelvy Tab. You say that the enrollee has tried and failed other
medications. The Plan denied your request. The Plan says this is not a Part B drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drug requested here is not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ubrelvy Tab.
Benefits for Ubrelvy Tab may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chemotherapy and related services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.
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 chemotherapy and related services to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says three hours of therapy a day is not needed. 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services or to require regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR, outpatient rehabilitation). 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that The Plan denied your request. The Plan says the provider is not an in-network provider, and prior authorization was not obtained.
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 services 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 October 10, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not stable for transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that the enrollee is likely to benefit from and improve with 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.