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

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer device.

You asked the Plan to pre-approve the Vertiflex Superion Interspinous Spacer device. The Plan denied your request. The Plan says this 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 Vertiflex Superion Interspinous Spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that 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. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L4-5 is 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 Vertiflex Superion Interspinous Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous Spacer device.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided June 26, 2020.
You asked the Plan to pay for the oxygen supplies provided during ambulance transport. You say that the claim should be covered. The Plan denied your request. The Plan says this service is not separately payable.
The Plan must follow Medicare rules. The rules say that the cost of oxygen and its administration in connection with and as part of the ambulance service is covered. Under the ambulance fee schedule (FS), oxygen and other items and services provided as part of the transport are included in the FS base payment rate and are NOT separately payable. pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen supplies provided during ambulance transport have not been met. Specifically, the record shows the enrollee was provided emergency ambulance transport. The oxygen supplies provided during the ambulance transport are not separately billable. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies, life sustaining situation (A0422) provided June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection provided on March 16, 2021 by an out of network provider.
You asked the Plan to pay for injection (20552). You say that your doctor sent a letter approving the services. The Plan denied your request. The Plan says you did not obtain prior authorization.
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 had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the injection provided on March 16, 2021 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our reviewer says that the requirements for coverage of Aranesp have not been met. Our physician reviewer found the Plan requires a trial of Retacrit before they will approve the requested drug. In this case, the patient has not tried and failed the Retacrit. There is no documentation provided indicating that the Retacrit would likely be less effective or have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device.
You asked the Plan to pre-approve Vertiflex Superion device. The Plan denied your request. The Plan says this 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 Vertiflex Superion device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that current evidence-based medical guidelines 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. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-4 and L4-5 is 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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient detoxification/chemical dependency admission.
You asked the Plan to pre-approve inpatient detoxification/chemical dependency admission. You say that you would like reconsideration because you were urgently referred for these services. The Plan denied your request. The Plan says your care needs may be met in a different setting.
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 inpatient detoxification/chemical dependency admission. Our reviewer says that based upon review of the records provided, you do not meet the criteria for acute inpatient mental health/detoxification treatment. You were not shown to be a danger to yourself or others and were without agitation or aggression without perceptual disturbance including auditory or visual hallucinations. Our physician reviewer found the documentation does not indicate that you were showing any signs or symptoms of alcohol withdrawal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient detoxification/chemical dependency admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient detoxification/chemical dependency admission.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychological testing.

You asked the Plan to pay for psychological testing. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that psychological tests when mental illness is not suspected would be a screening procedure not covered by Medicare. 

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 psychological testing. Our reviewer says that psychological testing is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not carry a mental health diagnosis and has not been treated for any psychiatric illness. The enrollee does not meet the criteria for authorization of psychological testing based on the LCD as he has no psychiatric/psychological diagnosis and is believed that this could be accomplished by outpatient treatment with a physician.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychological testing have not been met. Therefore, we decided that the Plan does not have to pay for psychological testing.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on February 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.

The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported. 

We looked at the file and Medicare rules. The records show that two E&M services were reported by the same provider on the same date of service. CPT code 99283 has been paid by the Plan, which means that CPT code 99285 is not payable. 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 the services (99285) provided on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed. 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 the drug testing services provided on March 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided a physical therapy assistant on September 3, 2020.
You asked the Plan to pay for physical therapy. The Plan denied your request. The Plan says the billed code is not appropriate for the service provided.
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy provided a physical therapy assistant on September 3, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on December 27, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for ambulance services provided on December 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on March 15, 2021.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.

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 physical therapy services. 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 physical therapy services provided on
March 15, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on February 13, 2021.

You asked the Plan to waive the copayment for emergency care. You say that you cannot afford the charges. 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 $120 copayment for emergency care.

You have been asked to pay a $120 copayment for emergency care. Emergency care falls within the emergency care 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 emergency care provided on February 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for oxygen concentrator equipment provided on March 22, 2021.

You asked the Plan to waive the coinsurance for oxygen equipment. You say that the home health provider states you should only be charged 10%. The Plan denied your request. The Plan says the coinsurance amount you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for oxygen equipment. The allowed amount of this claim is $142.96, resulting in a coinsurance amount of $28.59. 

You have been asked to pay 20% coinsurance for oxygen equipment. Oxygen equipment falls within the Durable Medical Equipment (DME) and Related Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for oxygen concentrator equipment provided on March 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a multiplane services coded 20692 and fluoroscopy services coded 76000 provided on December 8, 2020.

You asked the Plan to pay for the application of a multiplane services and fluoroscopy services. You say that you feel this claim should be paid. The Plan denied your request. The Plan says the services are not payable as billed.

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 codes 20692 and 76000 are not supported in the medical record. Specifically, these codes were billed with place of service 11 (outpatient). The documentation shows that the enrollee was inpatient during this date of service. Based on this information, we decided that Medicare rules for coverage of the application of a multiplane services and fluoroscopy services have not been met.

Therefore, we decided that the Plan does not have to pay for the application of a multiplane services coded 20692 and fluoroscopy services coded 76000 provided on December 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the supervision, handling, loading of radiation source coded
77790 provided on March 15, 2021.
You asked the Plan to pay for the supervision, handling, loading of radiation source. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed
with an invalid modifier.
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 77790 is supervision, handling, loading of radiation
source.
We find that CPT code 77790 is not supported in the medical record. Specifically, this code was billed with
modifier 26. This code is a technical component only code and modifiers 26 and TC cannot be used with this
code. This means this code was billed with an invalid modifier. Based on this information, we decided that
Medicare rules for coverage of the supervision, handling, loading of radiation source have not been met.
Therefore, we decided that the Plan does not have to pay for the supervision, handling, loading of radiation
source coded 77790 provided on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services billed with diagnosis related group (DRG) 602.
You asked the Plan to pay for inpatient services billed with DRG 602. You say that the services provided were medically necessary, reasonable, and appropriate for this enrollee's diagnoses and condition. The Plan denied your request. The Plan says the diagnosis of toxic encephalopathy is not supported, and therefore DRG 602 is not supported. However, the Plan states that DRG 603 is supported in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. DRG 602 requires a diagnosis of toxic encephalopathy. In this case, you billed the inpatient services provided with DRG 602. 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 inpatient care with DRG 602. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found that the record does not support the presence of acute toxic encephalopathy. The elements of the coverage criteria are not satisfied, and therefore the requested services cannot be recommended as billed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services billed with diagnosis related group (DRG) 602.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted after a motor vehicle accident and was found to have widely metastatic adenocarcinoma, thought to be pancreatic in origin.
Your medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 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 inpatient rehabilitation facility (IRF) admission and services.