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

We decided that the Plan does not have to pay for a zoster (shingles) vaccine (90750) and administration (90471).
You asked the Plan to pay for a shingles vaccine and administration. You say that you were told this would be covered. The Plan denied your request. The Plan says this vaccine is covered under Medicare Part D.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for a zoster (shingles) vaccine (90750) and administration (90471).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the claim was not submitted timely per Medicare criteria.
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 claim for the home infusion therapy services was not filed until x. 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 for the home infusion therapy services provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 robotic-assisted rehabilitation device.
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 the services are experimental/investigational in nature and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee had a cervical spine injury at the C4 to C8 levels. There is ongoing arm weakness, fatigue, and lack of coordination. The requested MyoPro device is not strongly supported by peer-reviewed science. It is considered experimental and investigational in nature and is a convenience item. The services are therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 robotic-assisted rehabilitation device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power Operated Vehicle Group 1 (K0800).
You asked the Plan to pre-approve the power operated vehicle. You say that you need a new power scooter. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power operated vehicle. Our reviewer says that the power chair requested is not medically necessary. Our physician reviewer found the records show the enrollee is currently using a walker. The enrollee's current power scooter can be repaired. A replacement is not medically necessary at this time. 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 power operated vehicle. have not been met. Therefore, we decided that the Plan does not have to pre-approve a Power Operated Vehicle Group 1 (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that your card does not state that you would owe 20% coinsurance for the drug injection. 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug. The allowed amount is $1,156.80 and 20% of that is $231.36. You have been asked to pay the total coinsurance amount of $231.36 for a Medicare Part B drug. A Medicare Part B drug 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 waive the coinsurance for a Medicare Part B drug.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve percutaneous image-guided lumbar decompression surgery
(0275T).
You asked the Plan to pre-approve the surgery. You say that you would like reconsideration because this
service is medically necessary for the treatment of the member's condition. The Plan denied your request. The
Plan says that the requested MILD/PILD at left L2-3 is not medically necessary and not clinically appropriate
based on the medical records and current literature.
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 surgery. Our reviewer says that the
requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found records document that the enrollee meets the inclusion/exclusion criteria and is participating in
the CED Longitudinal Study (NCT 03072927), a Medicare approved clinical trial. The enrollee meets the NCD
coverage criteria for percutaneous image-guided minimally invasive lumbar decompression (MILD/PILD) at
the L2/3 level.
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 surgery have been met. Therefore, we decided that the Plan has to preapprove
percutaneous image-guided lumbar decompression surgery (0275T).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit and coinsurance for injections provided by a participating provider.
You asked the Plan to waive the copayment for a specialist office visit and coinsurance injections. You say that you did not know that the injection cost was going to be so high. The Plan denied your request. The Plan says the correct copayment and coinsurance have been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for physician/practitioner services/specialist services and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay an $80 ($40 x 2 visits = $80) copayment for a specialist office visit and a 20% coinsurance of the allowed amount for injections. The total allowed amount is $6,424.80. The amount you are being asked to pay for injections is $1,284.96 ($6,424.80x 20% = $1,284.96). The total amount you are being asked to pay is $1,364.96 ($1,284.96 + $80 = $1,364.96). A specialist office visit falls within the physician/practitioner services/specialist services benefit category. 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 waive the copayment and coinsurance for a specialist office visit and injections provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the train of four testing (CPT 95999).
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that all services which are integral to accomplishing a procedure are considered a component part of a comprehensive code. IONM services cannot be performed without TOF monitoring. This means that TOF testing is considered integral to the performance of IONM services. As such, this component of the procedure is included in payment for the overall IONM monitoring service which was already paid. No separate payment can be made for this part of the service. Therefore, we decided that the Plan does not have to pay for the train of four testing (CPT 95999).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care.
You asked the Plan to pay for the acute inpatient hospital care. The Plan denied your request. The Plan says that inpatient care was 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 the 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 that the enrollee presented to the ED, after a fall at home. She stated her left knee gave out and she fell hitting her head and right hip. On evaluation, her vital signs were stable and physical exam was notable for drowsiness, confusion and left knee swelling. She was treated with IV fluids and analgesics and admitted to telemetry. She was evaluated by Orthopedics and no surgical intervention was required. Her condition stabilized and improved and she was discharged to a skilled nursing facility when considered medically stable. The review has determined that the record showed that at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier 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 the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-invasive home ventilator (E0466).
You asked the Plan to pre-approve the ventilator. You say that you would like reconsideration because this
ventilator is medically reasonable and necessary. The Plan denied your request. The Plan says the records do
not show that the member has tried and failed Bi-Pap at home.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory
failure due to COPD.
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 ventilator. Our reviewer says that
there is no evidence that the enrollee has used home CPAP/BiPAP, or that such use has resulted in intolerance
or treatment failure. There is no evidence that the enrollee has a neuromuscular disorder or restrictive thoracic
disease. Our physician reviewer found the use of a home ventilator is not currently shown to be medically
necessary or reasonable.
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 ventilator have not been met. Therefore, we decided that the Plan does not
have to pre-approve a non-invasive home ventilator (E0466).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat.
You asked the Plan to pre-approve a raised toilet seat. You say that you need the raised toilet seat because there
is not a railing in most public bathrooms to help you stand up and the seats are not high enough for you. You
say you have a bad left knee, an imbalanced gait and a crushed rotator cuff in your shoulder that cannot be
repaired. You stated that the raised toilet seat would help you will these issues. You say that the requested toilet
seat would enable you to leave your home and improve your quality of life. The Plan denied your request. The
Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered
because they are not primarily medical in nature.
While a raised toilet seat may be appropriate for you, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair with seat cushion.
You asked the Plan to pre-approve the requested wheelchair. The Plan denied your request. The Plan says you are able to ambulate with a rolling walker.
The Plan follows Medicare rules. Medicare rules say that manual wheelchairs are only covered under certain medical indications.
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 requested wheelchair. Our physician reviewer found that you have known lumbar spine stenosis and persistent pain. Treatments have included medications (opiates) and back brace use. There is no documented neurological deficit. You are not noted to have an inability to utilize a lesser device, such as a walker. Therefore, the request is not medically 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 requested wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair with seat cushion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide an implanted osteogenesis stimulator (20975).You asked the Plan to provide the stimulator. You say that the stimulator is medically necessary.The Plan denied your request. The Plan says coverage criteria has 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 provide the stimulator. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found insufficient time has passed to establish nonunion of the ankle fracture.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 stimulator have not been met.Therefore, we decided that the Plan does not have to provide an implanted osteogenesis stimulator (20975).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were not given a warning about the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug. The allowed amount is $1,086.12 and 20% of that is $217.22. You have been asked to pay the total coinsurance amount of $217.22 for a Medicare Part B drug. A Medicare Part B drug 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 waive the coinsurance for a Medicare Part B drug.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a psychiatric diagnostic evaluation.
You asked the Plan to pay for evaluation. You say that you depend on the facility for timely notification of the enrollee's health insurance coverage and ask that payment be allowed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
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 claim for evaluation was not filed until x. 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 for a psychiatric diagnostic evaluation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets criteria for a LTACH.
The Plan denied your request. The Plan says admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found that the enrollee is receiving necessary services and is at an appropriate level of care
in the acute care hospital. Continued care at this level is appropriate until the patient is stable to transfer to a
lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility or sub-acute
rehabilitation facility.
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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you were in need of
emergency assistance. Your friend found you unconscious at your desk and called for an ambulance. You say
that the EMT responders discovered the problem and administered an IV with sugar. After you began to
respond, you say the responders explained the situation to you and gave you the option of going to the hospital.
You stated that they said the hospital may just tell you the same thing that they were, and so you declined
transportation. You say that you did not expect to be held liable for the bill and thought you were saving money
since you could now take care of yourself. You say that the ambulance responders saved your life and you
asked the Plan to pay the bill since you live on a limited income. The Plan denied your request. The Plan says
these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 8, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat facet joint injection.
You asked the Plan to pre-approve the facet joint injection. You say that this should be allowed due to medical necessity. The Plan denied your request. The Plan says the criteria for repeat injections have not been met in this case.
The Plan follows Medicare rules. These rules state that repeat facet joint injections can only be covered when the above criteria are met for amount and duration of pain relief. 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 facet joint injection. Our reviewer says that the documentation does not support the medical necessity of the requested injection. Our physician reviewer found the patient did not achieve the greater than 80% pain relief required by the LCD. The therapeutic injection on 2/24/20 provided 60% relief. On 3/13/20, the request for the second injection was only 2-3 weeks after first injection. Based on letter dated 4/3/20, the duration would have only been 6 weeks. This does not meet the Medicare criteria for diagnostic or therapeutic facet joint injections. In addition, there is no documentation of any facet loading tests to support that the pain is coming from the facet joints. 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 facet joint injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat facet joint injection.