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

We decided that the Plan does not have to waive the copayments for the colonoscopy and biopsy provided on July 23, 2020.
You asked the Plan to waive the copayments for the colonoscopy and biopsy. You say that this was a routine, preventive care colonoscopy and it should have been paid at 100%. 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 $250 copayment for Medicare-covered outpatient services at hospital facilities and a $25 copayment each Medicare-covered specialist visit. You have been asked to pay a total of $275 copayment for the colonoscopy and biopsy. The colonoscopy and biopsy fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category and the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows a diagnosis code for benign neoplasm of colon which makes the colonoscopy diagnostic in nature. See chart below.
Date of Service
Service
Provider
Allowed Amount
Copayment
Member Liability
July 23, 2020
Colonoscopy and biopsy
Facility
$1,433.85
$250
$250
July 23, 2020
Colonoscopy and biopsy
Physician
$298.99
$25
$25
Total
$275
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 copayments for the colonoscopy and biopsy provided on July 23, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered from this condition for three (3) years and has greatly impacted their quality of life. You state you feel the Vertiflex Superion Interspinous device is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the device(s) is helpful for treatment for the enrollee's health problem.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has lumbar spinal stenosis with claudication. The magnetic resonance imaging (MRI) lumbar spine from April 2021 demonstrates severe spinal stenosis at L2-L3, L3-L4 and greater than moderate spinal stenosis at L4-L5. The requested service is to treat L2-L3 and L3-L4. These levels have severe spinal stenosis. The elements of the coverage rule are not satisfied. The requested service is not 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the cervical spine provided on
March 8, 2021.

You asked the Plan to waive the copayment for a CT scan of the cervical spine. You say that you should have
been told by the provider that you would have a copayment for the services. The Plan denied your request. The
Plan says the copayment you are being charged is correct.

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 $250
copayment for outpatient diagnostic tests and therapeutic services and supplies in an outpatient hospital setting.

You have been asked to pay a $106.60 copayment for a CT scan of the cervical spine. The record shows the Medicare Allowed Amount is $106.60, which is lower than your copayment of $250 per the EOC. A CT scan of the cervical spine falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the cervical spine (72125) provided on March 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the spine surgery procedure (Intracept Procedure) (22899).

You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept procedure remains experimental for the treatment of low back pain. More research is needed to show safety and efficacy of this procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.

Therefore, we decided that the Plan does not have to pre-approve the spine surgery procedure (Intracept Procedure) (22899).
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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home or an assisted living facility with home health services or in a long-term care facility on a part time basis appear appropriate in this case. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code 81404, 81406, 81439, 81479) provided to the enrollee on October 31, 2020.
You asked the Plan to pay for the testing. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Review of the file shows that the enrollee had cardiovascular risk assessment testing on October 31, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing (CPT code 81404, 81406, 81439, 81479) provided to the enrollee on October 31, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided to the enrollee on September 27, 2020.
You asked the Plan to pay for the stimulator. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) code E0745-RR 99 KJ KX (1 Unit) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code E0745 is "Neuromuscular stimulator, electronic
shock unit." We asked our coding 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 stimulator. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the services were billed by one provider, but the delivery ticket documents that the services were delivered by a different provider. There is no documentation to support that these two companies are affiliated. Therefore, it cannot be confirmed that the equipment was actually supplied to the enrollee. We looked at this coder'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 pay for a neuromuscular stimulator (E0745) provided to the enrollee on September 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on October 7, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the claim was not submitted with the required modifier.
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 exercises to develop strength, endurance, range of motion and flexibility." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found per the Medicare Claims Processing Manual; "The GN, GO, or GP therapy modifiers are currently required to be appended to therapy services. In addition to the KX modifier, the GN, GP and GO modifiers shall continue to be used". Therefore, the services were incorrectly reported.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional injection of substance into lower spine canal using imaging guidance (62323).
You asked the Plan to pre-approve an additional injection of substance into lower spine canal using imaging guidance. You say that this request is medically necessary. The Plan denied your request. The Plan says they are not able to cover an additional injection per the LCD rules.
The Plan must follow Medicare rules. Medicare rules say that only one caudal or lumbar interlaminar injection per session is allowed
We looked at the file and Medicare rules. In this case, the file indicates that the Plan will approve one injection but is denying the second per the LCD rules. Based on this information, we decided that Medicare rules for coverage of an additional injection of substance into lower spine canal using imaging guidance have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional injection of substance into lower spine canal using imaging guidance (62323).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Carboplatin and Paclitaxel.
You asked the Plan to pre-approve Carboplatin and Paclitaxel. You say that the requested drugs are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the drug regimen is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Carboplatin and Paclitaxel. Our reviewer says that the requested drugs are medically necessary for the enrollee's medical condition. Our physician reviewer found the enrollee is a 66-year-old female with stage IV non-small cell lung cancer. In this case, the requested drugs are not approved by the FDA for the enrollee's condition. However, there is support in the Medicare-approved Compendia for their use in non-small cell lung cancer. In addition, these drugs can be considered safe and effective and otherwise reasonable and necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Carboplatin and Paclitaxel have been met. Therefore, we decided that the Plan has to pre-approve Carboplatin and Paclitaxel.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation
is needed. The Plan denied your request. The Plan says the benefit has been exhausted.
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 24 one-way transportation 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns - porcelain fused to predominantly base metal (D2751) for teeth 6, 7, 8, 9 and 11.
You asked the Plan to pre-approve crowns for teeth 6, 7, 8, 9 and 11. You say that the existing crown has an open margin and was done incorrectly and needs to be replaced and the condition of your front teeth is highly sensitive and causes severe pain. The Plan denied your request. The Plan says the teeth do not appear to have significant breakdown.
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 crowns for teeth 6, 7, 8, 9 and 11 when the services are medically necessary and reasonable and prior authorization criteria are 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 pre-approve crowns for teeth 6, 7, 8, 9 and 11.
Our reviewer says that the service is not medically necessary. Our physician reviewer found the patient's dental record and radiographs do not show significant coronal breakdown of teeth 6, 7, 8 and 11. Tooth 9 has a crown in place. There is no indication as to why the crown needs to be replaced. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of crowns for teeth 6, 7, 8, 9 and 11 have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns - porcelain fused to predominantly base metal (D2751) for teeth 6, 7, 8, 9 and 11.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered with back for ten (10) years that has impacted the enrollee's quality of life. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion device placement at L4-5 is not medically reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the excision, of a malignant lesion (11642), laboratory services (88305, 88342), adrenalin epinephrine injections (J0171, J0171-JW), and the bupivacaine liposome injection (C9290) provided on February 6, 2020.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the cost share has been applied correctly to the services provided.
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 20% coinsurance for outpatient surgery provided by an in-network provider. You pay a $50 copayment for laboratory services provided at an in-network outpatient hospital. Additionally, you pay a 20% coinsurance for Medicare Part B drugs rendered by an in-network provider. You have been asked to pay $658.65 which includes $598.98 ($2,994.88 x 20% coinsurance) for the outpatient surgery, a $50 copayment for the laboratory services, and $6.75 ($33.77 x 20% coinsurance) for the Medicare Part B drug, $1.69 ($8.44 x 20% coinsurance) for the Medicare Part B drug, and $1.23 ($6.15 x 20% coinsurance) for the additional Medicare Part B drug provided. 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 cost share for the excision, of a malignant lesion (11642), laboratory services (88305, 88342), adrenalin epinephrine injections (J0171, J0171-JW), and the bupivacaine liposome injection (C9290) provided on February 6, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral blepharoplasty for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate additional photos taken with the upper lid skin retracted to show the actual position of the true lid margin.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has dermatochalasia. The submitted visual field testing is labelled as low test reliability. The photograph submitted claiming a MRD of 2 mm is of poor quality and not interpretable as the eye appears completely black. The elements of the coverage rule 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral blepharoplasty for the enrollee.