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

We decided that the Plan does not have to pre-approveinsertion of an interlaminar stabilization device (Superion Vertiflex procedure).You asked the Plan to pre-approveVertiflex procedure. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is considered experimental or investigational at this time.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence-based medical guidelines and peer reviewed literature do not support this spinal decompression device 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 Vertiflex for the enrollee's medical condition under these conditions. There is no specific rational as to why standard surgical decompression would not be indicated. There are no X-Ray reports or discussion relative to spinal alignment to confirm the absence of scoliosis and instability. There is no documentation of radicular symptoms or signs/symptoms of neurogenic claudication in the medical records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approveinsertion of an interlaminar stabilization device (Superion Vertiflex procedure).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on May 2, 2019.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 submitted records do not support the billing of codes 49084 or 49320-59 and 44050-59.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 49320 is laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure). The definition of code 44050 is reduction of volvulus, intussusception, internal hernia, by laparotomy. The definition of code 49084 is peritoneal lavage, including imaging guidance, when performed.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 these services. Our reviewer says that the submitted records do not support the billing of codes 49084 or 49320-59 and 44050-59. Our physician reviewer found CPT 49320 was submitted with a 59 modifierto indicate that the procedure was a separately performed procedure. The medical records submitted do not corroborate that CPT 49320 was performed as a procedure unassociated with (not a part of) the Enterectomy. Therefore, separately billing CPT 49320 with a 59 modifier 
for additional reimbursement consideration in inappropriate. CPT 44050 was submitted with a 59 modifier to indicate that the Reduction of volvulus, intussusception, internal hernia, by laparotomy was a separately performed procedure. Themedical records submitted do not corroborate that CPT 44050 was performed as a procedure unassociated with (not a part of) the Enterectomy. Therefore, separately billing CPT 44050 with a 59 modifier for additional reimbursement consideration in inappropriate.The medical records provided do not include documentation of a peritoneal lavage, including imaging guidance, when performed being performed on May 2, 2019. The description for code 49084 was not documented in the operative note.We looked at this physician's review, the file, and Medicare rules. 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 services rendered on May 2, 2019
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight home health skilled nursing visits per week.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says one visit per week is approved but eight visits per week are not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have been receiving home skilled nursing and therapy. You are on insulin daily and all other medications are oral. You do not have any complex skilled nursing needs. You have no complex wound care needs or intravenous (IV) medications. The records do not support that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for you.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve eight home health skilled nursing visits per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants for tooth #'s 22, 27 and 29.You asked the Plan to pre-approve the endosteal implants. You say that you have found that the floor of your mouth is completely flat and there is no defined interior jawline/ridge for your original dentures to adhere to. You also say that you were told your only option for teeth is to have these implant posts surgically inserted into your jaw so you can then attach your denture.The Plan denied your request. The Plan says this service is not covered under your benefit package.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.Therefore, we decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implants for tooth #'s 22, 27 and 29.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by an in-network provider from January 29, 2019 through January 31, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that there was a blizzard and you were told by hospital personnel that it was medically unsafe to release you during a state of emergency. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 inpatient hospital care provided by an in-network provider from January 29, 2019 through January 31, 2019. You are asked to pay $250 copayment per day, days 1-2 of your inpatient care (January 29, 2019 through January 30, 2019). You were discharged on January 31, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-7. 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 inpatient hospital care provided by an in-network provider from January 29, 2019 through January 31, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you fora wig purchased on July 24, 2019.You asked the Plan to reimburse you for the wig. You say that you need a wig because of your medical condition.The Plan denied your request. The Plan says wigs are not covered by Medicare or the Plan.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. Medicare rules say that a cranial prosthesis is statutorily excluded.Therefore, we decided that the Plan does not have to reimburse you fora wig purchased from on July 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the ophthalmic biometry, and cataract surgery to be provided by an in network provider at an out of network facility.
You asked the Plan to pre-approve the ophthalmology services. You say that your vision has gotten worse. You say that you need to be able to see in order to do your job. You say that the provider cannot perform the surgery at an in network facility until January. You also say that you have other surgeries scheduled for December and January. The Plan denied your request. The Plan says the provider has access to in network facilities. The Plan also says the cataract surgery is not emergent.
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 pre-approved care. Although the requested provider in this case is a network provider with the Plan, the requested facility is not a network provider with the Plan. The Plan has network facilities 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 ophthalmic biometry, and cataract surgery to be provided by an in network provider at an out of network facility.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the INTRACEPT procedure.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says this is considered 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 procedure. Our reviewer says that
the requested procedure is not considered medically reasonable and necessary in this case. Our physician
reviewer found this is an experimental and investigational procedure. It is deemed 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the INTRACEPT procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) on September 14, 2019 to September 21, 2019.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says services were billed with an invalid code.
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 S9328 is not supported in the medical record. Specifically, Per the 2019 Year National Physician Fee Schedule Relative Value File July Release, procedure code S9328 has a status code of "I" which is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) on September 14, 2019 to September 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora 3D rendering with interpretation and reporting (76376) provided on August 19, 2019.You asked the Plan to pay fora 3D rendering with interpretation and reporting. You say that this was medically necessary.The Plan denied your request. The Plan says the LCD criteria have not been met.The Plan must follow Medicare rules. Medicare rules say that 3-D rendering and interpretation must be billed with one of the secondary diagnosis codes listed above.We looked at the file and Medicare rules. The claim submitted in the documentation does not include a secondary diagnosis code. Based on this information, we decided that Medicare rules for coverage of a 3D rendering with interpretation and reporting have not been met.Therefore, we decided that the Plan does not have to pay fora 3D rendering with interpretation and reporting (76376) provided on August 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on June 26, 2019.You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 a drug test provided on June 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 19, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 July 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for an eye examination provided on June 7, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and 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 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 for an eye examination provided on June 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla 30mg tablets.
You asked the Plan to pre-approve Otezla. You say that the Otezla is medically necessary. The Plan denied your request. The Plan says coverage for self-administered drugs like Otezla is not available under the Medicare Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Otezla 30mg tablets.
Benefits for Otezla 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated scooter.You asked the Plan to pre-approve the scooter. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show why a walker or a manual wheelchair would not help.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found there is no evidence concerning an inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this request is not medically 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 scooter have not been met.Therefore, we decided that the Plandoes not have to pre-approve a power operated scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and panoramic radiographic imaging (D0330) with out of network provider.You asked the Plan to pre-approve these services. You say that you do not understand why the dental services have been denied as your doctor referred you to this particular dental provider.The Plan denied your request. The Plan says services are only covered if rendered by an in-network provider. The records do notshow that your dental provideris an in-networkprovider with the 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. We looked at the case file and the Plan'srules. Based on this information, we decided that the Plan's rules for coverage of these services have not been met.Specifically, dental services are being requested from an out of network dental providerwith the Plan. The dental benefit only provides coverage for services rendered by an in-network provider. Therefore, we decided that the Plan does not have to pre-approvea comprehensive oral evaluation (D0150) and panoramic radiographic imaging(D0330) with the out of network dental provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics to be provided by the out of network provider.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 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 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 foot orthotics to be provided by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152 and 99153) provided on January 29, 2019.You asked the Plan to pay for sedation services. You say that these codes are supported.The Plan denied your request. The Plan says the medical records submitted do not include documentation of the presence of an independent trained observer.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 definitions of codes 99152 and 99153 are moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older, and each additional 15 minutes intraservice time (List separately in addition to code for primary service).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 sedation services. Our reviewer says that CPT codes 99152 and 99153 are not supported by the medical record. Our physician reviewer found the documentation does not contain evidence that an independent, trained observer was present and assisted with monitoring the patient during the moderate sedation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met.Therefore, we decided that the Plan does not have to pay for sedation services (99152 and 99153) provided on January 29, 2019.