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

We decided that the Plandoes not haveto pre-approveoperative tissue ablation and reconstruction for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthere remains a lack of consensus on patient selection, and long term outcomes.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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the failed ablations, left atrial enlargement, obesity, hypertrophic cardiomyopathy and failure of amiodarone, the likelihood of maintaining long-term normal sinus rhythm is very low. In this circumstance if additional atrial fibrillation ablation is still thought to be necessary (as opposed to accepting atrial fibrillation) then this may be accomplished percutaneously as an endocardial catheter-based ablation and has also been performed surgically with limited success.  Current guidelines consider surgical atrial fibrillation ablation appropriate in case when the procedure is performed in conjunction with other cardiac surgical procedures such as coronary bypass or valve repair/replacement, neither of which is being considered in this case. While surgical atrial fibrillation ablation has been performed as a 'stand-alone' procedure in various forms there are presently no controlled trials comparing surgical atrial fibrillation ablation approaches to catheter based percutaneous ablation. There have been no head-to-head comparisons of the outcomes of catheter and surgical ablation of atrial fibrillation. According to current guidelines, "the referral of patients for surgery with symptomatic, medically refractory atrial fibrillation in lieu of catheter ablation remains controversial."  In this particular case, there is no contraindication to repeat percutaneous catheter based ablation such as inadequate venous access or prosthetic cardiac devices precluding cardiac access to the left atrium. Therefore, a 'stand-alone' surgical atrial fibrillation procedure should be considered investigational 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveoperative tissue ablation and reconstruction for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar sympathetic blocks (64520).
You asked the Plan to pre-approve the lumbar sympathetic blocks. You say that the member has ongoing left thigh and lower back pain and you are requesting the blocks to identify the cause of the radicular pain. The Plan denied your request. The Plan says this service 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 the lumbar sympathetic blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have complex regional pain syndrome 1 or 2 using the Budapest criteria. 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 lumbar sympathetic blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar sympathetic blocks (64520).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care from October 1, 2019 through October 4, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you were expecting to only be in the hospital a night or two, but instead you were admitted for three (3) days.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 shows that you were admitted on October 1, 2019 and discharged on October 4, 2019. You were asked to pay a $310 copayment per day from October 1, 2019 through October 3, 2019, days 1-3 of your inpatient hospital care. You were discharged on October 4, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $310 copayment per day required for days 1-6. 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 forinpatient hospital care from October 1, 2019 through October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral knee injections provided on April 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the injections. You say that you have been receiving gel knee injections from this provider since 2018. You also say that you were unaware that your policy changed from Medicare Cost to Medicare Advantage. The Plan denied your request. The Plan says authorization was not obtained before you received the injections. The Plan also says the services could have been provided in Plan.
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 for the bilateral knee injections provided on April 25, 2019 by an out of network (OON) provider.
MAXIMUS Federal Services read your letter and knows that you may have a question regarding your enrollment in the Plan. MAXIMUS Federal Services cannot answer enrollment questions. MAXIMUS Federal Services is sending a copy of your case file and your letter to the San Francisco CMS Regional Office so that it can look into your enrollment question.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 28, 2019 through September 28, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were 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 portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 28, 2019 through September 28, 2019. You have been asked to pay 20% coinsurance of the allowed amount for DME. The allowed amount per date of service is $66.38. The total you owe per date of service is $13.28 ($66.38 x 20% = $13.28). You are being billed for three (3) months; therefore, the total you owe is $39.84 ($13.28 x 3 months = $39.84). 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 portable oxygen contents, gaseous, 1 month's supply = 1 unit (CPT Code E0443) provided from July 28, 2019 through September 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8, 2019 through October 9, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from October 8, 2019 through October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible
protective outer surface covering system (L5962) for the enrollee.
You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no
documentation that supports that the member's activity subjects her to harsh environmental situations or that
she engages in any extraordinary activities that would justify the need for extra protection with a flexible outer
surface covering system.
The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is
used by a beneficiary who has special needs for protection against unusually harsh environmental situations.
We looked at the file and Medicare rules. The record does not show the enrollee is subject to harsh
environmental situation. 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 addition,
endoskeletal system, below knee, flexible protective outer surface covering system (L5962) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that one of your legs is shorter than the other so you need a shoe lift to help relieve hip pain.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee onDecember 27, 2018.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified. 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 laboratory services rendered to the enrollee on December 27, 2018.
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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the member is receiving the appropriate inpatient care and does not require transfer to a LTACH.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 it would be most appropriate to continue acute care services at the current facility until stable enough for discharge to a lower level of care. The required physical therapy and monitoring can be completed in the current setting, and there were no needed services which would only be available at the proposed LTACH.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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to enrollee on July 1, 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 services are not covered.The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 9 represents a code for which the concept of a professional/technical component does not apply.The provider submitted claims for procedure codes 80053, 83735, 83880, and 85025 with modifier -26. These codes have a PC/TC indicator of 9 and the concept of a PC does not apply.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to enrollee on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on July 8, 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 procedure code 99356 is not supported.
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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service). We find that CPT code 99356 is not supported in the medical record. Specifically, the records do not contain documentation of one hour of prolonged inpatient services spent on the enrollee. 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 July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bupivacaine injection provided on September 11, 2019 billed with code S0020.
You asked the Plan to pay for the bupivacaine injection. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says this code is not valid for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S0020 has a status indicator of "I", meaning that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the bupivacaine injection have not been met. Therefore, we decided that the Plan does not have to pay for the bupivacaine injection provided on September 11, 2019 billed with code S0020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on July 10, 2019 to August 20, 2019.
You asked the Plan to waive the copayment for physical therapy. You say that no one ever told you about a copayment. You say that you only found out after you received a bill. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for outpatient rehabilitation services. You have been asked to pay a $35 copayment for each physical therapy. The total amount you are being asked to pay is $350 ($35 x 10 visits = $350). Physical therapy falls within the outpatient rehabilitation 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 physical therapy provided. on July 10, 2019 to August 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on September 9, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were informed you would only owe $65. You say that this was a single visit. 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 $65 copayment for urgently needed services at an out-of-network urgent care center. You have been asked to pay a $65 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed 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 the urgent care visit provided on September 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on a hysteroscopy (58558) provided on March 20, 2019.
You asked the Plan to pay for surgical assistant services. You say that these services were medically necessary. The Plan denied your request. The Plan says surgical assistant services are not covered for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 58558. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services on a hysteroscopy (58558) provided on March 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with the physician, an oral surgeon.You asked the Plan to pre-approve the dental service. You say that you need to see a specialist. You say that in 1990 you were kicked in the face and your jaw was broken on both sides and most of your teeth were lost. You say that you received a bone graft and removable dentures from provider that no longer fit in your mouth. You also say that you have lost 25 pounds because you are unable to eat properly.The Plan denied your request. The Plan says the services are not medically reasonable and necessary.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. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the information provided concerning the enrollee's ill-fitting prosthesis and difficulty with proper mastication in my opinion does not meet the criteria for consultation with an oral maxillofacial surgeon. Examination by a general dentist or prosthodontist to determine the reasons for the enrollee's denture problem would be primary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met.Therefore, we decided that the Plan does not have to pre-approve a consultation with a physician, an oral surgeon.