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

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device. You say that you cannot stand or walk, and this is not an experimental procedure. The Plan denied your request. The Plan says the interspinous spacer procedure is considered experimental and cannot be approved.

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 insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is relatively limited evidence to guide the use of surgery for the management of lumbar spinal stenosis, as there are no published placebo-controlled trials investigating the effects of surgery for this condition. Most of the evidence supporting the use of surgery comes from randomized trials comparing surgery with non-surgical interventions, with conflicting conclusions.

The addition of fusion to decompression is not only more costly, but also leads to more intraoperative blood loss and longer operation time and fails to result in superior clinical outcomes when compared with decompression alone. An operation using interspinous spacer devices is quicker, and results in less blood loss and shorter hospital length of stay than fusion. These devices, however, do not provide better outcomes than conventional decompression, and are associated with higher reoperation rates.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 9, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers are required to submit sufficient documentation to determine whether payment is due for billed services.
In this case, no progress note was submitted for the November 9, 2020 date of service. The note submitted is dated November 9, 2019. If this is dated in error, the note would require an official signed amendment per Medicare regulations. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on November 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on February 25, 2021.

You asked the Plan to waive the copayment for the laboratory work. You say that the laboratory work was for the routine annual wellness exam. You say you were sent to the hospital because the primary care physician lab was closed. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 $40 copayment for laboratory services at an in-network outpatient hospital. 

You have been asked to pay a $40 copayment for the laboratory work. The laboratory work falls within "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 the laboratory work provided on February 25, 2021.
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 you need professional help to get healthy enough to live by yourself. The Plan denied your request. The Plan says you do not need an intensive program or intensive therapies.
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. Our physician reviewer found there are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does 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 this patient 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 Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 43274 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 43274 is endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent. We find that CPT code 43274 is not supported in the medical record. Specifically, there is no documentation of placement of endoscopic stent into biliary. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided January 28, 2021.
You asked the Plan to pay for the dental exam, cleaning, and bitewing x-rays. You say that you have been seeing this provider for years and felt uncomfortable going to a different provider since you do not know their disinfecting procedures during the pandemic. The Plan denied your request. The Plan says this provider is not contracted with the Plan and the Plan had other providers who could have rendered the same care therefore the services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental exam, cleaning and bitewing x-rays when the services are medically necessary and reasonable.
We looked at the file and Medicare rules. The requested provider in this case is not a network provider with the Plan at the time of the service. 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. Based on this information, we decided that the Plan's rules for coverage of the dental exam, cleaning and bitewing x-rays have not been met. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and bitewings - four radiographic images (D0274) provided January 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foran inpatient admission provided from January 23, 2019, through February 6, 2019.You asked the Plan to pay forthe inpatient admission. The Plan denied your request. The Plan says the claim was received past the timely filing limit of 12 months.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claimfor the inpatient admission was not filed until October 28, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay foran inpatient admissionprovided from January 23, 2019, through February 6, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kanjinti.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says services related to a clinical trial are not covered. The Plan must follow Medicare rules. The rules state that Original Medicare pays for the routine costs of qualifying clinical trials. We looked at the file and Medicare rules. The file shows that Kanjinti is being requested as part of a clinical trial. The Plan cannot approve these services, as approval is required through Original Medicare. Therefore, we decided that the Plan does not have to pre-approve Kanjinti.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forextractions (D7140) provided on December 22, 2020.You asked the Plan to pay forextractions. You say that you want the Plan to pay for the services at issue.The Plan denied your request. The Plan says you are responsible for services provided byprivately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of extractions have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider.Therefore, we decided that the Plan does not have to pay forextractions (D7140) provided on December 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on January 13, 2021.
You asked the Plan to pay for the 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 for the services provided to you by an out-of-network provider on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on December 9, 2020.You asked the Plan to pay for the denture. You say that you signed up for this plan because the Plan's representative told you that dentures were covered.The Plan denied your request. The Plan says dentures are not covered by your dental benefit.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 requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) provided on December 9, 2020.Your complaint about potential misinformation that influenced your choice in insurance plan 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on June 18, 2020.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 97110 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were rendered in the home or hospice setting and there is a more appropriate code for these services. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on June 18, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 21, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you do not see doctors very often and do not take any medical drugs. You say that the Plan should consider waiving the copayment. 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 $165 for each type of Medicare-covered diagnostic radiology service including MRI, CT scans, nuclear scans and PET scans, per date of service. You have been asked to pay a $165 copayment for the MRI. The MRI 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 the MRI provided on January 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gammagard liquid injections provided from December 5, 2020, to February 20, 2021.
You asked the Plan to pay for the Gammagard injections. You say that you initially told the doctor that you could not afford the $600 copayment. You say that you received a call from a clinic that said the services would be covered. You say that you received a bill in February 2021. You say that you were let go from your job due to Covid-19. You also say that you wish you would have known it would not have been covered sooner so that you could have discontinued the infusions sooner. The Plan denied your request. The Plan says the claims were processed correctly with a member liability of $1,826.33.
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 Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the Gammagard injections. the Gammagard injections falls
within the Medicare Part B prescription drugs 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 pay for the Gammagard liquid injections provided from December 5, 2020, to February 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on October 28, 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 October 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intraoral x-rays (D0220, D0230), fluoride application (D1206) and unspecified preventative procedure (D1999) provided on February 9, 2021.
You asked the Plan to pre-approve the dental services. You say that you do not understand why these services are not covered. The Plan denied your request. The Plan says these services are not covered by your dental benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 30, 2020 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. 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 office visit provided on November 30, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a medical sauna for use in the home.

You asked the Plan to pre-approve the medical sauna. You say that you have tried many different treatments for your pain over the years and most have not been very helpful or caused adverse side effects. You have had access to a steam room/sauna in the past, and this was the only thing that truly helped reduce your pain as well as other issues, such as skin and sinus problems. You feel that in your case, this would be medically necessary. The Plan denied your request. The Plan says this is not a covered item.

The Plan must follow Medicare rules. Medicare rules say that in order to be considered DME, an item must be primarily medical in nature.

The Qualified Independent Contractor (QIC) read your letter and all documents in the case file. It is understood that this type of treatment has helped more than many other attempted treatments. Although this may be appropriate for you, Medicare is not allowed to cover a sauna bath/steam room as it is not considered primarily medical in nature. This means that it does not fall into a covered benefit category for which Medicare or your Plan is authorized by law to make payment. Therefore, we decided that the Plan does not have to pre-approve a medical sauna for use in the home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physician's vision services provided on February 2, 2021.You asked the Plan to waive the copayment for the physician's vision services. The Plan denied your request. The Plan says the claim processed 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 $35 copayment for Medicare covered vision care. You have been asked to pay $35 copayment for the physician's vision services. The physician's vision services falls within the Medicare covered vision 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 physician's vision services provided on February 2, 2021.