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

We decided that the Plandoes not haveto pre-approvethe Vertiflex Superion interspinous and/or interlaminar device for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not proven that this device is helpful for treatment of spinal stenosis with neurogenic claudication.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 fileand 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presents with complaints of chronic low back pain. Pain interferes with quality of life and activities of daily living. She has reportedly failed conservative treatment, including medications, spinal injections, and activity modification. Under consideration is a request for the Vertiflex Superion interspinous device at L4/5 for treatment of her spinal stenosis. 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 indications include implantation of the Superion device at one or two adjacent lumbar levels for moderate spinal stenosis in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. These indications have not been met. There is reported imaging evidence of moderate to severe spinal stenosis at L3/4 and L4/5 and bilateral foraminal stenosis at L5/S1, and the treatment plan indicated that the device was recommended at the L2/3 and L4/5. There is no imaging report available for review in the submittedmedical records. The medical records do not clearly document signs/symptoms consistent with the reported neurogenic claudication. FDA contraindications include osteoporosis, and this has not been adequately addressed in the medical records. There is no discussion indicating that a DEXA scan has demonstrated no osteoporosis in this post-menopausal 82-year-old female who has radiographic evidence of osteopenia. Superior indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Therefore, this request does not meet Medicare criteria as medically reasonable and necessary for treatment of 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 Plandoes not haveto pre-approvethe Vertiflex Superion interspinous and/or interlaminar device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve suction-assisted lipectomy of the legs.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there are no indications of what kind of therapy has been attempted.
The Plan must follow Medicare rules. Medicare rules say that plastic surgery must be done for reconstructive reasons, not cosmetic reasons. 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 services are not considered medically reasonable and necessary in this case. Our physician reviewer found liposuction of the lower extremities to treat lipedema is an accepted form of surgical management. However, reasonable conservative management should be fully exhausted prior to surgical treatment. Based on the documentation provided, this has not been sufficiently documented. You were seen for an initial evaluation by a lymphedema clinic, and were instructed on reasonable conservative management. However, you do not appear to have continued this treatment as instructed, including appropriate follow-up. The planned procedure should not be considered cosmetic treatment, just that reasonable conservative management had not been sufficiently documented. 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 suction-assisted lipectomy of the legs.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve10 physical therapy (PT) visits.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee had right knee surgery on February 3, 2020. He has had 10 prior PT visits and is now compliant with a home exercise program. The requested PT visits are generally not accepted as specific and effective therapy for his condition. The records do not show that he needs the unique skills of a professional therapist are required to safely and effectively provide treatment. The requested services are not part of a maintenance program and are not needed to maintain the enrollee's current condition or prevent further deterioration. The services are 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve10 physical therapy (PT) visits.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. The Plan denied your request. The Plan says your benefit only allows 12 trips for this service.
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. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan's maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora shoulder x-ray (73030) provided on August 15, 2019.You asked the Plan to pay for the shoulder x-ray. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says this claim has been correctly denied as a duplicate as the services were billed by the same provider, diagnosis, date of service, CPT and modifiers.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shoulder x-ray have not been met. Specifically, the record indicates that the Plan previously processed and paid2 units of CPT code 73030.Therefore, we decided that the Plan does not have to pay fora shoulder x-ray (73030) provided on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided on November 4, 2019.You asked the Plan to pay forthe wrist hand orthosis. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.The Plan must follow Medicare rules. The rules state that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity ofitems ordered and for the frequency of use or replacement(if applicable). The record shows that the Plan made several attempts to obtain the documentation to validate an established relationship with the ordering physician, along with documentation of the duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and previously received DME items related to the billed items. The record does not include sufficient information to validate the billed supply codes.Therefore, we decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided on November 4, 2019
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve Computed Tomography (CT) of the head (70450).You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says that coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our reviewer says that a CT scan is medically necessary. Our physician reviewer found based on the medical records received, the history of getting lost while driving and the inability to recall any items on three item recall tests are concerning for cognitive decline or dementia for which computed tomography of the head is medically appropriate.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 CT scan have been met.Therefore, we decided that the Plan has to pre-approve Computed Tomography (CT) of the head (70450).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 foroutpatient lab work provided on October 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 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 foroutpatient lab work provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forlimited oral evaluation -problem focused (D0140) and core buildup, including any pins when required (D2950) provided on January 14, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the services are not a covered benefit under 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.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 pay forlimited oral evaluation -problem focused (D0140) and core buildup, including any pins when required (D2950) provided on January 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endosteal implants (D6010) prefabricated abutment (D6056) bone graft at time of implant placement (D6104) provided December 10, 2019.
You asked the Plan to pay for the dental services. You say that you are writing this appeal as a pleat to allow for any benefit to be allowed to help defray the cost to the enrollee for his dental treatment. The Plan denied your request. The Plan says this service is not covered under the plan benefits.
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 pay for endosteal implants (D6010) prefabricated abutment (D6056) bone graft at time of implant placement (D6104) provided December 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 29, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that the service should be covered as preventive. You say that you shouldn't be responsible for the bill.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan mustdisclose 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 $200 copayment for Medicare-covered services provided at an ambulatory surgical center.You have been asked to pay a $200 copayment for the colonoscopy. The colonoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that two polyps were removed, which 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 paywhen you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe colonoscopy provided on October 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on July 10, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the enrollee last saw the ordering physician in 2018 and there was no face-to-face encounter.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There are no medical records around the time of service from the ordering physician supporting medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on July 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939).You asked the Plan to pre-approve bone marrow aspiration. You say that the requested bone marrow aspiration is medically necessary.The Plan denied your request. The Plan says the requested bone marrow aspiration is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspiration. Our reviewer says that the requested bone marrow aspiration is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of Spondylosis without myelopathy or radiculopathy in the cervical region, Radiculopathy, cervical region. She has neck pain and numbness. The symptoms have not responded to epidural injections, facet blocks, physical therapy, and over the counter medication. An anterior cervical disc fusion is planned. The available documentation in the case file does not support the medical necessity of bone marrow aspiration for bone grafting. Bone marrow aspiration is not considered the standard of care for the treatment of the enrollee's cervical condition. There is insufficient support for this procedure in the peer-reviewed medical literature.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration (20939).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe specialist office visit, the Part B injection, the emergency room visit, and the multiple x-rays provided from August 22, 2019 to January 3, 2020.You asked the Plan to waive the cost share forthe specialist office visit, the Part B injection, the emergency room visit, and the multiple x-rays. You say that you should not be responsible for the charges because the services should be covered under theglobal period and that the serviceswere done as follow-ups to the surgery.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 $45 copayment for each in-network Medicare-covered visit with a specialist after your yearly deductible is met,  20% coinsurance for each in-network Medicare-covered Part B drug obtained in a provider's office or outpatient setting after your yearly deductible is met, an $80 copayment for each Medicare-covered emergency room visit, and a $35 copayment per day, per provider for in-network Medicare-covered x-ray services after your yearly deductible is met. You have been asked to pay a total of $242.16for the specialist office visit, the Part B injection, the emergency room visit, and themultiple x-rays. The specialist office visitfalls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" benefit category. The emergency roomvisit falls within the "Emergency care" benefit category. The multiple x-rays fallwithin the "Outpatient diagnostic tests and therapeutic services and supplies"benefit category. The record shows you had previously met your in-network deductible. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to 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 cost share forthespecialist office visit, the Part B injection, theemergency room visit, and multiplethex-rays provided from August 22, 2019 to January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for immediate denture -maxillary (D5130), immediate denture -mandibular (D5140) and drugs or medicaments dispensed in the office for home use (D9630) provided on December 18, 2019.You asked the Plan to pay forthe dental services. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says you exceeded your maximum benefit.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.Per your claim history, the $1,000 benefit max was met when the claim was processed. Your EOC clearly states, there is a $1000 annual maximum (after the annual maximum is exhausted, any remaining charges are your responsibility).Therefore, we decided that the Plan does not have to pay forimmediate denture -maxillary (D5130), immediate denture -mandibular (D5140) and drugs or medicaments dispensed in the office for home use (D9630) provided on December 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug infusion supplies rendered on September 9, 2019 to October 1, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid proof of delivery.The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 forthe drug infusion supplies rendered on September 9, 2019 to October 1, 2019.