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

We decided that the Plan does not have to pre-approve an interspinous decompression spacer procedure.

You asked the Plan to pre-approve Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee has suffered for greater than 10years. The Plan denied your request. The Plan says Medical studies haven't proven that the device is helpful for treatment of the enrollee's back pain.

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, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has had a prior laminectomy and has multiple levels of disease. The record does not state that the enrollee is not indicated for operative treatment. The record indicates that flexion worsens the pain. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous decompression spacer procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zephyr valve placement procedure.

You asked the Plan to pre-approve Zephyr valve placement. You say that treatment with Zephyr valves is the most appropriate treatment option to improve all aspects of the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered investigational for the enrollee's 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 Zephyr valve placement. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record includes pulmonary function testing results, but the documentation is insufficient to demonstrate that the accepted criteria for Zephyr endobronchial valves have been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zephyr valve placement have not been met. Therefore, we decided that the Plan does not have to pre-approve Zephyr valve placement procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services 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. 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below his baseline. Given his three recent hospitalizations, a period of skilled therapy for strength and endurance training is reasonable. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical extractions provided on January 21, 2021.

You asked the Plan to pay for the surgical extractions. You say that your coverage should have covered 70% of the bill and you are owed a refund of $244.86 The Plan denied your request. The Plan says surgical extractions are not a covered 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, surgical extractions are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical extractions provided on January 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown or pay more for the resin-based composite provided on February 8, 2021, and March 29, 2021 by an OON provider.

You asked the Plan to pay for the crown and to pay more for the resin-based composite. You say that you were wondering if the Plan would cover any of these charges. The Plan denied your request. The Plan says crowns are not a covered service. The Plan also says that the resin-based composite was performed by an OON provider, and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the service.

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, crown is not among those covered under this benefit. The contract says that you are responsible for a 55% coinsurance for resin-based composites, plus the difference between the billed amount and allowed amount for resin-based composites that are received OON. Therefore, we decided that the Plan does not have to pay for the crown or pay more for the resin-based composite provided on February 8, 2021, and March 29, 2021 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hi-tech rad, duplex scan of the lower extremity arteries and veins (93971).
You asked the Plan to pre-approve the duplex scan. You say that the enrollee is in need of ultrasound imaging due to having right leg pain, calf muscle tenderness and pain when walking to rule out DVT.
The Plan denied your request. The Plan says the non-invasive physiologic ultrasound of the arteries of the legs is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the duplex scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the provided documentation is insufficient to establish that significant signs or symptoms of arterial or venous disease is present. No physical examination findings are documented in support of the requested tests. The medical necessity and reasonableness, as defined by Medicare rules is not established by the provided documentation. 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 duplex scan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hi-tech rad, duplex scan of the lower extremity arteries and veins (93971).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established
patient (D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and
including elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon
You asked the Plan to pre-approve a comprehensive oral exam and tooth extraction performed by an oral
surgeon. You say that it is necessary to have the services performed by an oral surgeon. The Plan denied your
request. The Plan says these services are not covered when performed by an oral surgeon.
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 a
comprehensive oral exam and tooth extraction performed by a participating provider.
We looked at the file and Medicare rules. The services being requested in this case will not be performed by a
participating provider. Based on this information, we decided that the Plan's rules for coverage of a
comprehensive oral exam and tooth extraction performed by an oral surgeon have not been met. Therefore, we
decided that the Plan does not have to pre-approve a comprehensive oral evaluation - new or established patient
(D0150) and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including
elevation of mucoperiosteal flap if indicated (D7210) performed by an oral surgeon
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 would prefer to be admitted to an IRF because you feel it is the best chance for returning you to your prior independent and active lifestyle as soon as possible. You feel that you would benefit from intensive therapy and worry that you will not receive the same care in another setting. The Plan denied your request. The Plan says criteria for an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 that 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 do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary services can be provided in a different 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
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 an LTACH is medically necessary for this enrollee The Plan denied your request. The Plan says criteria for an LTACH are not met. The enrollee's needs are being met in the current acute setting, and an LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured, and the appropriate lower level of care can be determined.

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 appears to be unstable and requires additional short-term acute care services which can be safely provided in the current acute care facility for the time being until long-term needs are more clearly determined. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as there is no advantage to a transfer at this time.

Transfer to a lower level of care may be considered when treatment has been completed and the enrollee is more stable. 

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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you require transport to your dialysis. The Plan denied your request. The Plan says that your request exceeds the maximum count allowed per period.
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 covers a maximum of sixty (60) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 23, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you were told that colonoscopies were covered when you signed up with the Plan. 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 $175 copayment for outpatient surgery, including services provided at ambulatory surgical centers. The medical records show that you had polyps removed during a colonoscopy provided on March 23, 2021. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $175 copayment. You have been asked to pay a $175 copayment for a colonoscopy. A colonoscopy 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 copayment for a colonoscopy provided on March 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cataract eye surgery and associated procedures (66984, 66982, 65820), with an out of network provider.

You asked the Plan to pre-approve the cataract eye surgery and associated procedures. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is available by a provider in your network.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the cataract eye surgery and associated procedures (66984, 66982, 65820), with an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy electrical pump (E2402) provided on March 3 to April 23, 2021.

You asked the Plan to waive the coinsurance for a negative pressure wound therapy electrical pump. You say that you do not have enough income and disagree with the amount you are being charged. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for each Medicare-covered item of durable medical equipment. 

You have been asked to pay a combined $826, or 20% of the Medicare-allowed combined charge of $4,130, for a negative pressure wound therapy electrical pump. A negative pressure wound therapy electrical pump falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a negative pressure wound therapy electrical pump (E2402) provided on March 3 to April 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for home infusion services provided on January 15, 2021.
You asked the Plan to waive the coinsurance for home infusion services. You say that you have already paid upon delivery of prescription and are dissatisfied with the additional charges. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for home infusion therapy. You have been asked to pay $80.64, or 20% of the Medicare-allowed charge of $403.20, for home infusion services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for home infusion services provided on January 15, 2021.
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 16, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says neither the rendering provider nor the referring provider are contract providers.
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 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 out of network physician services provided to the enrollee on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam provided on
February 26, 2021.
You asked the Plan to waive the copayment for the eye exam. The Plan denied your request. The Plan says the claim processed appropriately according to the billing by the provider for the services rendered and the structure of your benefit plan.
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 $10 copayment for Vision Care. You have been asked to pay a $10 copayment for the eye exam. The eye exam falls within the 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 an eye exam provided on February 26, 2021.