Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on October 6, 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 payable under OPPS.
The Plan must follow Medicare rules. The rules say that an OPPS payment status indicator is assigned to every HCPCS code. We looked at the file and Medicare rules. Billed procedure code 77049 (breast MRI) has a status indicator of B under OPPS and is not recognized for payment. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) rendered on October 6, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dorzolamide-Timolol eye drops.
You asked the Plan to pre-approve Dorzolamide-Timolol eye drops. You say that you want the enrollee to be
treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's
Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Dorzolamide-Timolol eye
drops.
Benefits for Dorzolamide-Timolol eye drops 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: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost-sharing charges for an ultrasound of the heart. We decided that the Plan does not have to reduce the cost-sharing charges for an ultrasound of the heart to the amount you requested.
You asked the Plan to reduce the cost-sharing charges for an ultrasound of the heart. You say that you should not owe a copayment for an echocardiogram and did not receive a surgical procedure. The Plan says that the claims were processed correctly, and you are being charged the correct amount.
We decided that the Plan has to reduce the cost-sharing charges for an ultrasound of the heart from $225 to $10.
The Plan says that you must pay $225 for an ultrasound. However, based on the Plan contract, you cannot be asked to pay more than a $10 copayment. Therefore, we decided that the Plan has to reduce the cost-sharing charges for an ultrasound of the heart from $225 to $10.
We also decided that the Plan does not have to reduce the cost-sharing charges for an ultrasound of the heart to the amount you requested.
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 $10 copayment for an ultrasound. Therefore, we decided that the Plan does not have to waive the $10 copayment for an ultrasound of the heart.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for microsatellite instability analysis (CPT 81301) services provided to the enrollee on October 5, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says the concept of a professional/technical component does not apply for this service.
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 81301 is "microsatellite instability analysis (e.g., hereditary non-polyposis colorectal cancer, lynch syndrome), of markers for mismatch repair deficiency (e.g., BAT25, BAT26) includes comparison of neoplastic and normal tissue, if 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 the testing. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation supports that services were rendered in Place of Service (POS) 21 inpatient hospital. When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable, and is bundled into the facility payment. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for microsatellite instability analysis (CPT 81301) services provided to the enrollee on October 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on February 5, 2020.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says these supplemental benefits are only available when the services/items are obtained from a preferred provider in the Plan's vision network.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a preferred provider.
We looked at the file and the Plan's rules. The file shows that the vision services were not provided by the Plan's preferred vision provider. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for vision services provided on February 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient hospital procedure provided on July 14, 2020.

You asked the Plan to waive the copayment for an outpatient hospital procedure. You say that you thought that you would only owe a specialist 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 $225 copayment for an outpatient surgery or procedure. 

The record shows that you received an outpatient hospital procedure at an outpatient hospital facility on July 14, 2020. Therefore, you are responsible to pay the $225 copayment. 

You have been asked to pay a $225 copayment for an outpatient hospital procedure. An outpatient hospital procedure falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an outpatient hospital procedure provided on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Farxiga 10mg tablet for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no Part D coverage for this plan.
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 Farxiga 10mg tablet for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc (J7324).
You asked the Plan to pre-approve Orthovisc. You say that the Orthovisc is medically necessary. The Plan
denied your request. The Plan says criteria for coverage under Medicare Part B has not been met.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Orthovisc (J7324).
Benefits for Orthovisc 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound services (CPT 76982) provided to the enrollee on July 30, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this code cannot be paid, as it is bundled to CPT 76641.

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 76982 is "ultrasound, elastography; first target lesion." 

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 the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the provider billed CPT 76982 with CPT 76641, without an appropriate modifier to justify billing the two codes on same date of service. The documentation did not include clinical reports of services rendered, to support billing both codes on same date of service, therefore this claim was billed incorrectly and would not be covered. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for ultrasound services (CPT 76982) provided to the enrollee on July 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amniotic fluid Allograft (Q4177) injection.
You asked the Plan to pre-approve the amniotic fluid Allograft injection. You say that you have severe
osteoarthritis and cartilage loss. You say that your doctor felt the amniotic injections would have the best
results for your ankle. You say that your doctor has had good success with this procedure. You say that your
doctor does not think the surgical options would be beneficial. You also say that Medicare has covered this
procedure code. The Plan denied your request. The Plan says the requested drug is not medically reasonable or
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 amniotic fluid Allograft injection.
Our reviewer says that the requested amnion fluid allograft injection is not considered medically reasonable
and necessary in this case. Our physician reviewer found currently, amniotic fluid allograft injections are
utilized for the treatment of chronic wounds and ulcerations. The reviewer found they are not considered
standard of care for the treatment of osteoarthritic conditions. Guidelines advise that a treatment must be
considered safe and effective, not experimental, and considered standard of care. The reviewer found that in
this particular case, the use of amniotic fluid allograft injections is not considered standard of care for the
treatment of ankle osteoarthritis. Therefore, the reviewer found the requested amnion fluid allograft injection is
not medically reasonable and necessary at this time.
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 amniotic fluid Allograft injection have not been met. Therefore, we decided
that the Plan does not have to pre-approve amniotic fluid Allograft (Q4177) injection.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation services provided on November 21, 2020.

You asked the Plan to pay for the ambulance services. You say that transport was medically necessary due to the enrollee's condition. The Plan denied your request. The Plan says the enrollee did not have a covered indication for the services.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file, and Medicare rules. The records provided show the enrollee was seen in the emergency department for back pain. His lungs were clear, and his vital signs were stable. He was transferred to his residence. The records do not indicate that the enrollee's condition is such that other means of transportation could endanger his health. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation services provided on November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment a therapeutic continuous glucose monitor.

You asked the Plan to waive the copayment a therapeutic continuous glucose monitor. You say that this device is medically necessary. The Plan denied your request. The Plan says the criteria for coverage of the therapeutic continuous glucose monitor have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to waive the copayment a therapeutic continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient Apollo OverStitch endoscopic suturing system (43999).
You asked the Plan to pre-approve the Apollo Overstich procedure. You say that you are hoping this procedure will initiate the start of her weight loss journey with your office and help better these comorbidities. Please reconsider approving endoscopic revision of the gastrojejunostomy. The Plan denied your request. The Plan says medical studies have not proven that the service or procedure is helpful for treatment of the enrollee's health problem. The inpatient stay is also denied as it is associated with a procedure that is not covered.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Apollo Overstich procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient Apollo OverStitch endoscopic suturing system (43999).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar orthosis (L0642).
You asked the Plan to pre-approve a lumbar orthosis. You say that this item is medically necessary. The Plan
denied your request. The Plan says there is no evidence you need a new back brace.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have back brace provided September 2020. This item serves the same purpose as a
lumbar orthosis. There is no evidence that this current brace is unable to meet your medical needs. Therefore,
we decided that the Plan does not have to pre-approve a lumbar orthosis (L0642).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunizations and administration provided on October 20, 2020.
You asked the Plan to pay for Tetanus vaccine (90715), Poliovirus vaccine (90713), Haemophilus vaccine (90648), or immunization administration (90472). You say that the Plan should pay this claim. The Plan denied your request. The Plan says these vaccines are not covered by Medicare or the Plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Tetanus vaccine (90715), Poliovirus vaccine (90713), Haemophilus vaccine (90648), immunization administration (90472). The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to Tetanus vaccine (90715), Poliovirus vaccine (90713), Haemophilus vaccine (90648), immunization administration (90472). Therefore, we decided that the Plan does not have to pay for the immunizations and administration provided on October 20, 2020.
Benefits for Tetanus vaccine (90715), Poliovirus vaccine (90713), Haemophilus vaccine (90648), or immunization administration (90472) 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is considered safe and
effective. The Plan denied your request. The Plan says this is experimental.
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 insertion of a Vertiflex device. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found according to the Food and Drug Administration (FDA), the Vertiflex Superion
Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or
cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate degenerative
lumbar spinal stenosis. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels
of "moderate" spinal stenosis including the planned level of implantation L3-4 and L4-5. FDA
contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately
addressed 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 for coverage of the insertion of a Vertiflex device have not been met. Therefore, we decided
that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.

You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this service.

The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the above described criteria. 

We reviewed the file and the Medicare rules. We find that the enrollee does not meet criteria for coverage of a LDCT scan. Specifically, the enrollee's smoking history is indicated as 10 pack-years; however, there is some discrepancy of either a 10 pack-year or 20 pack-year history. Both of these estimates are below the required threshold for coverage, which is 30 pack-years. Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.