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

We decided that the Plan does not have to pre-approveSuperion interspinous spacer (Vertiflex device).You asked the Plan to pre-approveSuperion interspinous spacer. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are 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 Superion interspinous spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. The requested spacer is experimental. More research is needed to show safety and efficacy. In addition, the documentation does not support spinal instability. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Superion interspinous spacer have not been met.Therefore, we decided that the Plan does not have to pre-approveSuperion interspinous spacer (Vertiflex device).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe bone marrow aspiration (20939).You asked the Plan to pre-approvethe bone marrow aspiration. You say that this service is medically necessary.The Plan denied your request. The Plan says this treatment has not been proven helpful for the member's medical condition.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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical conditionWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approvethe bone marrow aspiration (20939)
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee is at or close to functional baseline.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a stroke. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 29, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe medical services provided to the enrollee by an out-of-network provider on September 29, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fordebridement provided from February 26, 2020, to March 25, 2020.You asked the Plan to waive the copayments fordebridement. You say that you disagree with the charges because you feel that you did not receive a surgical procedure.The Plan denied your request. The Plan says the claims were processed correctly and you are being chargedthe 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 $300 copayment for outpatient surgery,including services provided at hospital outpatient facilities. You received debridement at an outpatient hospital facility from February 26, 2020, to March 25, 2020, for a total of 4 visits. Debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $300 copayment per each visit. The total amount you owe is: $300 (copayment) x 4 (visits) = $1,200. You have been asked to pay the total copayment amount of $1,200 for debridement. Debridement falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments fordebridement provided from February 26, 2020, to March 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatient hospital care provided July 24, 2020 to July 28, 2020.You asked the Plan to waive the copayment forthe inpatient hospital care. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost-sharing was 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 $250 per-day copayment for Days 1-7 of inpatient hospital care. You have been asked to pay a $1,000 copayment for 4 days of inpatient hospital care. 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 provided July 24, 2020 to July 28, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on January 18, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says out-of-network services are not covered.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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 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 forthe medical services provided to the enrollee by an out-of-network provider on January 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe microslideconsultation (88321) provided on February 10, 2020.You asked the Plan to pay forthe microslide consultation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the maximum frequency per day for CPT code 88321 is one unit.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 88321is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the microslide consultation have not been met.Therefore, we decided that the Plan does not have to pay forthe microslide consultation (88321) provided on February 10, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foremergency care provided on October 13, 2020.You asked the Plan to waive the copayment foremergency care. You say that you request that the Plan help you pay for 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 $90 copayment for emergency care. You have been asked to pay a $90 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 foremergency care provided on October 13, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 hematemesis and fall, treated with exploratory laparotomy and colectomy and ileostomy. The enrollee was reintubated after surgery due to inability to protect airway. The enrollee had decreased responsiveness and Keppra was initiated. Later, the enrollee underwent thoracic fusion followed by continued mechanical ventilation support and tracheostomy and PEG placement. Recent notes showed that the enrollee was communicating more and tolerating trach collar. The enrollee does not require services at the LTACH that are not already available and covered at the current setting. There are no services at the LTACH that are not already available at the health care setting being offered by the plan.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit and an electromyography provided by a participating provider on March 2, 2020You asked the Plan to waive the copayment foran office visit and an electromyography. You say that you have never been charged for this before. The Plan denied your request. The Plan says the correct copayments have 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 $20 copayment for physician/practitioner services/specialist visit and $150 copayment for outpatient diagnostic tests/other diagnostic tests. You have been asked to pay a $20 copayment for an office visit and $150 copayment for an electromyography. The total amount you are being asked to payis $170 ($20 + $150 = $170). The correct copayments have been applied to the services that were provided. An office visit falls within the physician/practitioner services/specialist visit and an electromyography falls within the outpatient diagnostic tests/other diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an office visit and an electromyography provided by a participating provider on March 2, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.The Plan must follow Medicarerules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan wascorrect in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for left below the knee amputation and was discharged to skilled nursing for nursing care and rehabilitation care. The enrollee's medical conditions are stable. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. The enrollee's care needs can be met at a lower level of 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetwo routine transportation trips exceeding 50 miles.You asked the Plan to pre-approvetwo routine transportation trips exceeding 50 miles. You say that you live 63 and a half miles from the provider that you need to see.The Plan denied your request. The Plan says the requested trips exceed your benefit's mileage limit.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 coversroutine transportation when the one-way trip does not exceed 50 miles of driving distance.We looked at your request, the records in the case file, and the rules. The requested trips exceed the Plan's distance limit. Based on this information, we decidedthat the Plan's rules for coverage of routine transportation have not been met.Therefore, we decided that the Plan does not have to pre-approvetwo routine transportation trips exceeding 50 miles.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services provided on August 27, 2020.You asked the Plan to pay forthe radiology services (72170, 71045) provided on August 27, 2020. You say that the enrollee had multiple services on this day.The Plan denied your request. The Plan says this physician was paid for services on this day and the record does not support multiple services from this physician.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 72170 and 71045 arenot supported more than once, in the medical record, for this provider. Specifically, the records provided show one reviewfrom this physician. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met.Therefore,we decided that the Plan does not have to pay forradiology services provided on August 27, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires (A4557 x 2) provided on September 7, 2020.You asked the Plan to pay forthese items. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says that the lead wiresprovided do not meet Medicare criteria for payment.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 case file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met.Specifically, a TENS unit has been purchased in the previous twelve monthson April 30, 2020, May 30, 2020, and July 7, 2020. Medicare rules state that replacement of lead wires more often than every twelvemonths would rarely be reasonable and necessary. Additional records have not been provided to support the medical necessity of the additional lead wires provided. Therefore, we decided that the Plan does not have to pay forthe lead wires(A4557 x 2) provided on September 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe incision and drainage of a lesion in the thigh or knee region represented by CPT code 27301 and billed for date of service June 22, 2020.You asked the Plan to pay forCPT code 27301. You say that the service which remains in dispute is payable to the assistant surgeon.The Plan denied your request. The Plan says the payment to an assistant surgeon for the service which remains in dispute does not meet the requirements for approval.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.We looked at the file and Medicare rules. In this case, you billed assistant surgery services for CPT code 27301. 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 on this information, we decided that Medicare rules for coverage of CPT code 27301 have not been met.Therefore, we decided that the Plan does not have to pay forthe incision and drainage of a lesion in the thigh or knee region represented by CPT code 27301 and billed for date of service June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe anesthesia (D9223) provided on July 14, 2020.You asked the Plan to pay forthe dental service. You say that you had a tooth extracted. You say that sedation for the removal was denied. You saythat you have chronic health conditions. You also say that you needed to be sedated during this procedure.The Plan denied your request. The Plan says there is an allowance of $1,250 every year for preventive and comprehensive dental services. The Plan says that the annual allowance has been exhausted.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 annual allowance of $1,250 for dental services has been exhausted. The record shows that the Plan paid $392 for the dental services that you received on June 25, 2020, and $858 towards the dental services that you receive don July 14, 2020, thus exhausting the annual allowance. The Evidence of Coverage clearly states that you are responsible for any amount above the dental coverage limit. Therefore, we decided that the Plan does not have to pay forthe anesthesia (D9223) provided on July 14, 2020.