Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on December 13, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on December 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Neck, Chest, Abdomen and Pelvis (71260, 74177, 70491).
You asked the Plan to pre-approve the CT scans. You say that the CT scans are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scans. Our reviewer says that the CT scans are not medically necessary at this time. Our physician reviewer found the enrollee completed treatment more than 4 years ago. The prescriber did not indicate a suspicion of relapsed disease in the office note of 12/30/19. Therefore the requested CT scans are not medically reasonable and 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 CT scans have not been met. Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Neck, Chest, Abdomen and Pelvis (71260, 74177, 70491).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Osteogen ultrasound stimulator (E0760).You asked the Plan to pre-approve the ultrasound stimulator. You say that [Enter appellant's argument from appeal letter, e.g. "...you need SNF care."]The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]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 ultrasound stimulator. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the fracture has not been diagnosed as a nonunion, as three month's time has not elapsed nor are there two sets of radiographs separated by a minimum of 90 days to demonstrate no healing of the fracture site. This fracture is not noted to be a fracture of the skull or vertebrae, nor is the fracture tumor related. 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 ultrasound stimulator have not been met.Therefore, we decided that the Plan does not have to pre-approve an Osteogen ultrasound stimulator (E0760).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee on October 23, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services 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 these services.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approverepair of a power seat elevation feature.You asked the Plan to pre-approverepair of a power seat elevation feature. You say that the requested repairs are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repair of a power seat elevation feature have not been met.Therefore, we decided that the Plan does not have to pre-approverepair of a power seat elevation feature.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown for tooth #13.
You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says that due to x-rays
for a glass crown for tooth # 13 that shows the whole tooth above and below the gum line not being received,
the requested service is not justified.
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 crown
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 crown. Our reviewer says that the
service meets criteria for coverage. Our physician reviewer found the enrollee's dental records and radiographs
indicate that the criteria for coverage for replacement of the defective crown for tooth #13 have been met. Our
reviewer also found that the tooth exhibits a completed root canal and good bone support.
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 crown have been met. Therefore, we decided that the Plan has to preapprove
a crown for tooth #13.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist hand orthosis (L3916) provided to the enrollee on November 14, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the medical records do not support this service.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met. The documentation submitted did not indicate the provider discussed the need for the billed supply code; therefore the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay forwrist hand orthosis (L3916) provided to the enrollee on November 14, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea RemedePhrenic Nerve Stimulator implant (0424T).You asked the Plan to pre-approvea Remede Phrenic Nerve Stimulator implant (0424T). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says a phrenic nerve stimulator implant is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare says that a phrenic nerve stimulator implant is not covered as it is deemed not medically necessary. Based on this information, we decided that Medicare rules for coverage of a Remede Phrenic Nerve Stimulator implant (0424T) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Remede PhrenicNerve Stimulator implant (0424T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 19, 2019 through November 27, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the long hospital stay was due to you being given too much pain medicine. 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 show that you received inpatient hospital care from November 19, 2019 through November 27, 2019. You should have been asked to pay a $250 copayment per day for days 1-7 of the inpatient hospital care totaling: $1,750. However, the Medicare-allowed amount for the inpatient hospital care is less than the set $250 copayment per day, days 1-7; therefore, you have been asked to pay the lesser amount of $1,070.72 for the inpatient hospital care. Per your contract there is a $250 copayment per day required for days 1-7. 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 inpatient hospital care from November 19, 2019 through November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 1, 2019.You asked the Plan to pay forthis service. You say that this office visit should be covered by the Plan.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide theservices 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 these services.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on August 1, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from June 16, 2019 through June 18, 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 that 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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed 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 been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from June 16, 2019 through June 18, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from July 12, 2019 to August 2, 2019.You asked the Plan to pay forthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not havedaily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from July 12, 2019 to August 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forportable oxygen concentrator, rental (CPT Code E1392) provided on August 23, 2019.You asked the Plan to pay forthe DME. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the billing address referenced on the claims is invalid according to the information the Plan has on file. The Plan states a corrected claimand an updated W-9 is required for reconsideration forpayment.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. The Plan states has to submit the requested information and the denial of payment will be upheld pending the receipt of a corrected claim from the provider. No further action is required of you.Therefore, we decided that the Plan does not have to pay forportable oxygen concentrator, rental (CPT Code E1392) provided on August 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on January 3, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges because you received the wrong kind of scan. 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 $100 copayment for each CT scan. You have been asked to pay a $100 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a CT scan provided on January 3, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approvePuraPly AM application treatments (Q4196 and 15273).You asked the Plan to pre-approvethe PuraPly AM application treatments. You say that you would like reconsideration because you have had this treatment in the past.The Plan denied your request. The Plan says that PuraPly AM application treatments are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PuraPly AM application treatments. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found PuraPly Antimicrobial can be used to manage bioburden and to help control biofilm re-formation while supporting healing across a wide variety of wound types, regardless of severity or duration. PuraPly AMis a class II medical device, that has been 510(k) cleared by US Food and Drug Administration (FDA) and is intended for the management of acute and chronic wound management across a variety of wound types, including partial-and full-thickness wounds, pressure ulcers, surgical wounds, trauma. In this case, PluraPly demonstrated progress. You have tried and failed other treatments including hyperbaric oxygen and Santyl.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 PuraPly AM application treatments have been met.Therefore, we decided that the Plan has to pre-approvePuraPly AM application treatments (Q4196 and 15273).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. Ifwe decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout of network outpatient hemodialysis services at Clinic.You asked the Plan to pre-approve the out of network outpatient hemodialysis services. You say that the enrollee has severe PTSD and his wife needs to sit with him the entire time. You say that the commute is far from the enrollee's home. You say that the enrollee would like to be closer to home and closer to his environment. You say that this would be in the enrollee's best interest.The Plan denied your request. The Plan says the criteria for out of network care have not been met.Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from the enrollee's home who can provide outpatient hemodialysis services. Under Medicare rules, this means that contract providers are accessible to the enrollee.Therefore, we decided that the Plan does not have to pre-approveout of network outpatient hemodialysis services at Clinic
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L3-4 radiofrequency ablation (64635).
You asked the Plan to pre-approve L3-4 radiofrequency ablation (64635). You say that the requested L3-4 RFA is medically necessary. The Plan denied your request. The Plan says the requested L3-4 RFA does not meet criteria.
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 L3-4 radiofrequency ablation (64635). Our reviewer says that the requested L3-4 RFA does not meet criteria. Our physician reviewer found the enrollee has chronic low back pain that does not radiate. His physical exam is positive for facet joint loading. He has tried Gabapentin, Physical Therapy and Home exercise program. He has had 2 prior diagnostic sets of facet blocks each of which provided sustained pain relief but the pain has returned. The blocks however were, Bilateral L5-S1 and L4-L5. Bilateral L3-L4 facets were not blocked. RFA for L3-L4 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 L3-4 radiofrequency ablation (64635) have not been met. Therefore, we decided that the Plan does not have to pre-approve L3-4 radiofrequency ablation (64635).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion spacer.
You asked the Plan to pre-approve the Superion spacer. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Superion spacer. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed. 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 Superion spacer have been met. Therefore, we decided that the Plan does not have to pre-approve a Superion spacer.