Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on June 5, 2019 described by the fourth unit of CPT code 22853-AS.
You asked the Plan to pay for the fourth unit of code 22853-AS. You say that this should be paid based on medical necessity The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. The definition of CPT code 22853 is Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). 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 fourth unit of 22853-AS. Our reviewer says that the medical records submitted do not include documentation to validate a 4th unit of this code. Our physician reviewer found the records do support that this service was performed at three interdisc spaces and these three units were paid. There is no evidence this was performed on a fourth space. 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 fourth unit of 22853-AS have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on June 5, 2019 described by the fourth unit of CPT code 22853-AS.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard (K0861) and accessories.
You asked the Plan to pre-approve a power wheelchair, group 3 standard and accessories. You say that the requested items are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a power mobility device or a push-rim activated power assist device is covered when specific criteria is 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 a power wheelchair, group 3 standard and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no documented failure to address needs via a lesser device, such as a group one power mobility device (PMD) or scooter. The necessity is not established. This is a convenience item and 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 a power wheelchair, group 3 standard and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair, group 3 standard (K0861) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair attendant controller, push handles, and accessories (E2311, E2331, E2377, E2313).
You asked the Plan to pre-approve the wheelchair controller and accessories. You say that the controller and accessories are medically necessary. The Plan denied your request. The Plan says rules for coverage are not met.
The Plan follows Medicare rules. Medicare rules say that an attendant controller is only covered when it is medically necessary. Push handles are not a covered item. 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 wheelchair controller and accessories. Our reviewer says that the requested items are not medically necessary. Our physician reviewer found the documentation does not reveal that an attendant control system is medically necessary as the patient is able to operate a joystick controller on a power wheelchair independently. The push handles are not a covered item. 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 wheelchair controller and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a wheelchair attendant controller, push handles, and accessories (E2311, E2331, E2377, E2313).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999) provided on October 31, 2019. You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says Medicare guidelines say that this service is considered a bundled procedure as the cost is included in the cost of the primary procedure. The Plan must follow Medicare rules. Medicare rules say that services integral to accomplishing a procedure are considered bundled into that procedure and, therefore, are considered a component part of the comprehensive code. In this case, the train of four monitoring described by code 95999 is an integral part of the Intraoperative Neurophysiological Monitoring (IONM) being billed and is not separately payable for that reason. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic procedure (95999) provided on
October 31, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the taxi transportation services provided on
November 4, 2019 and November 8, 2019.
You asked the Plan to reimburse you for the taxi transportation services. You say that your surgeon told you
not to drive yourself after surgery. 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 taxi transport services.
The services you have asked the Plan to reimburse you for are taxi transport services. Therefore, we decided
that the Plan does not have to reimburse you for the taxi transportation services provided on November 4, 2019
and November 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on February 13, 2020.You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation does not support any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl Dis 25mcg/Hr.
You asked the Plan to pre-approve Fentanyl Dis 25mcg/Hr. You say that the requested medication is necessary.
The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a
separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for
coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pre-approve Fentanyl Dis 25mcg/Hr.
Benefits for Fentanyl Dis 25mcg/Hr may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
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 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing medication management, wound care, and daily therapy can be provided at a SNF. In this case, the enrollee is mostly contact guard assist for functional transfers and bed mobility and a less intensive, longer duration of therapy will allow for measurable gains to be attained.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty and Percutaneous vertebral augmentation services.
You asked the Plan to pre-approve kyphoplasty and Percutaneous vertebral augmentation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Percutaneous Vertebral Augmentation is only covered for certain 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 kyphoplasty and Percutaneous vertebral augmentation services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found Kyphoplasty above and below the fractures vertebra is not needed and does not meet criteria for coverage. It is not clinically indicated or supported by the peer review literature. Therefore, the enrollee does not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of kyphoplasty and Percutaneous vertebral augmentation services have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty and Percutaneous vertebral augmentation services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the shoulder injection provided on December 19, 2019.You asked the Plan to waive the copayment for the shoulder injection. You say that you cannot afford this copayment. The Plan denied your request. The Plan says you have been charged 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 surgery services atan in-network outpatient hospital. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the shoulder injection.You have been asked to pay a $230.09 copayment for the shoulder injection. The shoulder injection 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 the shoulder injection provided on December19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 12,
2019 and December 23, 2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
the enrollee must receive care from in-network providers with the exception of emergency or urgent care, or if
the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for subsequent nursing facility care provided on December 12, 2019
and December 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home ventilator use for the enrollee.You asked the Plan to pre-approve continued home ventilator use. The Plan denied your request. The Plan says that there is a lack of medical necessity based on poor compliance.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 continued home ventilator use. Our reviewer says that continued home ventilator use is not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have COPD. The enrollee has had a home ventilator for over a year and a half. Usage summaries show that the enrollee is non-compliant with home ventilator use. Our physician reviewer found the enrollee's condition does not meet Medicare criteria for continued home ventilator use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home ventilator use have not been met.Therefore, we decided that the Plan does not have to pre-approve continued home ventilator use for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pacemaker surgery provided from October 31, 2019 to November 1, 2019. You asked the Plan to waive the coinsurance for the pacemaker surgery. You say that you cannot afford to pay this outstanding balance. You say you were told you would have a $400 copayment and you would not have had the surgery if you knew it would cost $6,000. The Plan denied your request. The Plan says you have been charged 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 20%
coinsurance for Medicare-covered surgery or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay $5,888.85 which is 20% of the allowed amount for the pacemaker surgery. The allowed amount is $29,444.23. ($29,444.23 x 20% = $5,888.85). The pacemaker surgery falls within the "Outpatient Surgery and Other Medical 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 coinsurance for the pacemaker surgery provided from October 31, 2019 to
November 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the apicoectomy, premolar, first root (D3421), the apicoectomy, each additional root (D3430), and the retrograde filling provided on December 6, 2019.
You asked the Plan to reimburse you for the dental services. You say that you had an ongoing infection in your gum area with the possibility of a cyst. You say that after the biopsy, it was found that there was no cyst present. The Plan denied your request. The Plan says dental services outside of those covered by Medicare are not covered. The Plan says you do not have additional coverage beyond what Medicare covers and per Medicare, routine dental care is not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the apicoectomy, premolar, first root (D3421), the apicoectomy, each additional root (D3430), and the retrograde filling provided on December 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 9, 2019 to September 10, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the medical treatment this enrollee received was considered appropriate and medically necessary. The Plan denied your request. The Plan says that the medical necessity for a hospital admission was not established.
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 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 the enrollee was evaluated in the ED late on 9/9/2019. He was found to have cellulitis and skin breakdown of his right calf. While the ED provider slated the enrollee for observation status, the admitting provider placed the enrollee on inpatient status. Given the enrollee's history of diabetes and toe amputations, it was reasonable to believe that two midnights of care would be required to manage the enrollee's cellulitis. That the enrollee apparently responded quickly and was discharged after only one midnight in the hospital does not negate the reasonable belief that, at the time of admission, the enrollee would require two midnights 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 9, 2019 to September 10, 2019.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture provided from November 29, 2019 to December 30, 2019.
You asked the Plan to pay for acupuncture. You say that you were in a lot of pain and your doctors had tried everything. The Plan denied your request. The Plan says the denial of payment for these services is correct, because acupuncture is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for acupuncture provided from November 29, 2019 to December 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 69209 provided on December 31, 2019.
You asked the Plan to pay for CPT code 69209. You say that you would like the Plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. In this case, the enrollee received services (CPT code 69209) while in
an emergency room, an outpatient hospital setting on December 31, 2019. Per Medicare payment guidelines,
CPT code 69209 has a PC/TC indicator of 5 and payment may not be made for this code when provided to
patients in a hospital outpatient department. Therefore, we decided that the Plan does not have to pay for CPT
code 69209 provided on December 31, 2019.