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

We decided that the Plandoes not haveto pre-approvethe Superion Vertiflex procedure for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is currently not enough medical evidence to show that this is helpful and safe.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. FDA contraindications include scoliosis (Cobb angle greater than 10 degrees) and morbid obesity (body mass index > 40). These indications have not been met. There is no rationale why standard surgical decompression would not be indicated. There is radiographic evidence of severe multilevel lumbar degenerative disc disease. There is radiographic evidence of moderate levoscoliosis of the lumbar spine with no documentation of the Cobb angle. This enrollee's body mass index is 53. There is no MRI report available for review or discussed in the submitted providerrecords to support that there is no more than 2 levels of moderate stenosis. Additionally, this request is for a 2-level procedure but there is only one level documented by the provider. Therefore, this request for Superion indirect lumbar decompression is not reasonable and medically necessary for this enrollee's medical 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 the procedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Superion Vertiflex procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora new patient office visit provided on December 17, 2019.You asked the Plan to pay foroffice visit. You say that the enrollee has not seen 2 providers in this group with the same taxonomy within the past 3 years, therefore the billing of a new patient visit is correct.The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee had other evaluation and management services from the same physician group practice and specialty within the previous 3 years.The Plan must follow Medicare rules. Medicare rules say that for the purposes of office visit coding, a new patient is a patient who has not received any professional services from the physician or physician group practice (same physician specialty) withinthe previous 3 years. We looked at the file and Medicare rules. The record shows that this enrollee had received a professional service from this physician group practice (same physician specialty) less than 3 years prior to this visit, therefore the billing of a new patient visit code for this office visit is not appropriate. Based on this information, we decided that Medicare rules for coverage of office visit have not been met.Therefore, we decided that the Plan does not have to pay fora new patient office visit provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe rest home visit provided on January 2, 2020 by an out of network (OON) provider.You asked the Plan to pay forthese OON services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.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 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. Wefound no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe rest home visit provided on January 2, 2020 by an out of network (OON) provider.
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 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 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 you do not require the intensity of services provided atan IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. You are already ambulating 100 feet. Your care needs can be met at a lower level of care.We looked at this physician'sreview, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee is a single person who lives alone and is still learning to use his walker. You say that the enrollee is displaying cognitive issues and poor safety judgement. You say that, without further physical therapy and rehabilitation, the enrollee is at risk of another fall and that this could result in another injury. You say that the enrollee's doctor and nurse agree that further therapy from qualified professionals is what the enrollee needs in order to be stable again.The Plan denied your request. The Plan says the enrollee is not in need of skilled nursing care or daily skilled therapy.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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have a tracheostomy tube, new enteral feedings, complex wound care or other SNF level skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF. As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on October 29, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the provider being out-of-network.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 $25 copayment for specialist visits. You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on October 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe core build-up (D2950).You asked the Plan to pre-approvethe core build-up (D2950). You say that restoration is needed.The Plan denied your request. The Plan says this is 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe core build-up (D2950).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that you would like this claim reprocessed and approved for payment.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 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 forlab work provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe nursing facility  services (99497, 99306, 99496, 99309) provided on April 17, 2019 to April 22, 2019 by an out of network (OON) provider.You asked the Plan to pay fornursing facility  services. You say that these services should be paid.The Plan denied your request. The Plan says these services were not authorized.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 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 forthe nursing facility  services (99497, 99306, 99496, 99309) provided on April 17, 2019 to April 22, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership with "gym 2" from November 1. 2019 to November 30, 2019.You asked the Plan to reimburse you for the gym membership with "gym 2". The Plan denied your request. The Plan says youcannot simultaneously enroll in multiple programs.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules applyin this case. The Plan's rules for coverage of gym benefits have not been met because you were enrolled with "gym 1", which is a participating Fitness Center, from January 1, 2019 to December 31, 2019. Therefore, we decided that the Plan does not have to reimburse you for a gym membership with "gym 2" from November 1. 2019 to November 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe eye exam provided on September 24, 2019.You asked the Plan to waive the copayment forthe eye exam. You say that this was a routine eye exam. You say that you shouldn't have to pay 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 a $35 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.You have been asked to pay a $35 copayment for the eye exam. The eye exam falls within the "Vision care" benefit category. The records show that a medical eye exam was performed. This means that you have been asked topay 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 forthe eye exam provided on September 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on November 26, 2019.You asked the Plan to waive the copayment forthe ambulance transport. You say that you believed there was no charge for emergency ambulance transport.The Plan denied your request. The Plan says that applicable copays and coinsurance are contractual obligation.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 $225 copayment for Medicare-covered ambulance benefits. You have been asked to pay a $225 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance benefits benefit category. This means that you have been asked to pay the correct amount based on your contractwith 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 forthe ambulance transport provided on November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fortrain of four testing billed with CPT code 95999 for date of service July 9, 2019.You asked the Plan to pay forthe train of four testing. You say that the services in dispute were medically necessary.The Plan denied your request. The Plan says the Train of Four is considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.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 95999 is unlisted neurological or neuromuscular diagnostic procedure.We asked our coding specialist 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 train of four testing. Our coding specialist reviewer says that the enrollee does notmeet the criteria for billing or reimbursement consideration. Our coding specialist reviewer found the medical records provided do not include documentation of an unlisted neurological or neuromuscular diagnostic procedure being performed on July 9, 2019,there this service cannot be verified. The operative report indicates that Train of Four Testing was performed. Train of Four Testing is inclusive to the IONM, whether the IONM is primarily EMG based or MEP based. There is no CPT code available for use for Train of Four Monitoring, therefore it is inappropriate to use CPT 95999 for Train of Four Monitoring.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 train of four testing have not been met.Therefore, we decided that the Plan does not have to pay fortrain of four testing billed with CPT code 95999 for date of service July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder-elbow-wrist-hand orthosis provided on August 19, 2019.You asked the Plan to pay forthe shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says criteria for the orthosis was not met.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 shoulder-elbow-wrist-hand orthosis (L3960). Our reviewer says thatthe orthosis is not medically necessary. Our physician reviewer found the enrollee's chief complaint was shoulder pain, as well as back pain and knee pain. The documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the shoulder. 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 shoulder-elbow-wrist-hand orthosis (L3960) have not been met.Therefore, we decided that the Plan does not have to pay forthe shoulder-elbow-wrist-hand orthosis provided on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Vimpat provided on December 8, 2019.You asked the Plan to pay forthis drug. The Plan denied your request. The Plan says that this is not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe Vimpat provided on December 8, 2019.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 4, 2018 by an out of network (OON) provider.You asked the Plan to pay forthe office visit (99214). You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the services received were not authorized and are not payable.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 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 forthe medical services provided on December 4, 2018 by an out of network (OON) provider.
Appeal type: Lab
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 October 28, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.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 has network providers available who can provide 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 October 28, 2019.