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

We decided that the Plan does not have to waive the copayment for the foot x-ray provided on January 14, 2021.
You asked the Plan to waive the copayment for the foot x-ray. You say that you were under the assumption that there was a 90-day global period for post-operative care. You say that you are appealing the copayment for the post-operative charges. 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 $15 copayment for each Medicare-covered standard x-ray service.
You have been asked to pay a $15 copayment for the foot x-ray. The foot x-ray falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service 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 copayment for the foot x-ray provided on January 14, 2021.
Your complaint about the provider charging excessively is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says there appears to be some concerns that the devices are not as effective as surgical
decompression, and could lead to higher rates of re-operation.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found 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 in patients with moderate spinal stenosis in whom operative treatment is indicated at no
more than two levels, from L1 to L5. 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 interspinous device at L4-L5 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on January 19, 2021 by an out of network (OON) provider.

You asked the Plan to pay for the office visit. You say that the service was medically necessary, and the service was due to an emergency case. The Plan denied your request. The Plan says no prior authorization was obtained.

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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The medical record shows the enrollee was treated for a chronic condition. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 19, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the ophthalmological services provided on March 9, 2021.
You asked the Plan to reduce the copayment for the ophthalmological services. You say that this was a covered routine eye exam. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for Vision Care other provider. You have been asked to pay a $40 copayment for the ophthalmological services. The ophthalmological services fall within the Vision Care other provider benefit category. The provider has confirmed this was a medical visit. 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 reduce the copayment for the ophthalmological services provided on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures provided from December 16, 2020, to December 30, 2020.
You asked the Plan to pay for the therapeutic procedures. You say that the Plan should be responsible for the claims. The Plan denied your request. The Plan says they have removed the coinsurance for the manual manipulation of the spine procedures, but the therapeutic procedures are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures provided from December 16, 2020, to December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia for an eye procedure provided on March 8, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the anesthesia for an eye procedure. You say that both the facility and the provider are participating providers. You say no certification was required due to patient condition and the Covid-19 emergency. The Plan denied your request. The Plan says no prior authorization was obtained.
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 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 anesthesia for an eye procedure provided on March 8, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Bioness orthosis, neuromuscular electrical stimulator (E0770) and electrical stimulator supplies (A4595).

You asked the Plan to pre-approve neuromuscular electrical stimulator and supplies. You say that the enrollee has undergone a trial of Bioness for his right hand and has shown promising results. You believe the device will benefit him to use his right hand more efficiently and improve his neuromuscular recovery further. The Plan denied your request. The Plan says since the requested device is for the hand it is not covered. The submitted medical records do not show that the requested device will be used for walking.

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 neuromuscular electrical stimulator and supplies. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal evidence that the device is being used for disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy. The requested items are not being used for walking in a patient with a spinal cord injury. Medical necessity has not been met for the requested items.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular electrical stimulator and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the Bioness orthosis, neuromuscular electrical stimulator (E0770) and electrical stimulator supplies (A4595).
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 the clinical documentation provided supports the need for care in an LTACH. The Plan denied your request. The Plan says the LTACH services do not meet the criteria for medical necessary or appropriateness.
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 the enrollee was admitted to the current acute care hospital with a stroke and acute respiratory failure and was treated with mechanical ventilation. The course was complicated by DVT which was treated with a heparin drip that has since been discontinued. A trach and PEG were placed. The enrollee is vent-dependent, and weaning was initiated on June 7, 2021. The enrollee is tolerating a slow weaning process and tube feeds. The progress notes show that the enrollee appears to be gradually improving but requires additional short-term acute care services including additional weaning attempts which can be safely administered at the current facility until a lower level of care is appropriate. The enrollee is stable otherwise.
The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.

You asked the Plan to pre-approve the compression stockings. You say that this request is medically necessary for your condition. The Plan denied your request. The Plan says these stockings are not covered under any condition.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs to get into the SNF for
treatment of sepsis. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have
not been met. The Plan says that the enrollee does not have a need for skilled nursing or rehabilitation services.
The Plan says that the services needed can be received at a different setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications and had stable vital signs. The enrollee's lungs were clear, and he had a nephrostomy tube placed.
The enrollee received physical therapy in the acute hospital. The enrollee was at contact guard assist level with
functional mobility, including gait to 275 feet with a rolling walker. The enrollee required varying assist with
activities of daily living. There are no identifiable skilled nursing service needs. While there are identifiable
skilled therapy service needs, they are not required on a daily basis. The enrollee does not meet severity of
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen equipment provided on December 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for oxygen equipment. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this equipment is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 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 oxygen equipment provided on December 18, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 5, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.

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 the laboratory services are not supported in the medical record. Specifically, if one laboratory
procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report
only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte
assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately
describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted molecular pathology
procedure) with one unit of service or may report multiple individual CPT codes describing the component test
results when medically reasonable and necessary. This means the services rendered should be billed with code 81479. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on January 15, 2021.

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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The Plan covers routine chiropractic services from a network provider when medically necessary. 

The records show that the service at issue is not manual manipulation of the spine. The file shows that the provider billed codes 97140 (manual therapy techniques) and G0283 (electrical stimulation). These services are not covered when performed by a chiropractor. The services are not covered by your supplemental routine chiropractic benefit because they were not performed a Plan network provider. Therefore, we decided that the Plan does not have to pay for the chiropractic services rendered on January 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 19, 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 the provider did not bill as required by Medicare coding regulations.
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 the denied codes is: CPT 88104: Cell examination of body fluid CPT 88305: Surgical pathology, gross and microscopic examination
CPT 88312: Special stain including interpretation and report CPT 88361: Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody. We asked our coding 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 coding reviewer found the billed procedures should be billed with modifier 26 Professional Component. We looked at this coder'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 laboratory services provided to the enrollee on November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One injection.
You asked the Plan to pre-approve Gel-One. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says you must have a steroid injection first. The Plan says that there is no
documentation of a steroid injection and the response. The Plan also says that the drug is not medically
necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise reasonable and 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 Gel-One. Our reviewer says that Gel-
One is not medically necessary. Our physician reviewer found the provided documentation does not indicate
that the enrollee has received a knee intra-articular steroid injection and the clinical result. Therefore, the
reviewer found that the requested injection 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 Gel-One have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Gel-One injection.
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. The Plan denied your request. The Plan says you do not require an
intensive, complex, multidisciplinary approach to daily therapy.

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 physician reviewer found
that you have a past medical history of stroke with left sided hemiplegia, COPD, femur fracture in January
2021, diabetes, and peripheral vascular disease. You are living at home with increased weakness. Your medical
conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies,
including either physical or occupational therapy, in an intensive rehabilitation therapy program.

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.