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

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have an indication for coverage.


The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen therapy is 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 services. Our physician reviewer found that the enrollee has a large wound on her abdomen,thought to be calciphylaxis,or perhaps pyoderma gangrenosum. She has been treated with multiple courses of antibiotics. There cords do not show that the enrollee has a condition that is indicated for coverage. The records do not show that there are measurable signs of healing for at least 30-days of treatment with standard wound therapy. Therefore, the requested services are 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 requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on August 11, 2020, and August 25, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
approved in advance. 
 
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 had network providers 
available who could have provided 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 for the medical services provided to the enrollee by an out-of-
network provider on August 11, 2020, and August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 14, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forpodiatry services. You say that the provider told you that they took your insurance.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 14, 2020, by an out-of-network (OON) provide
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenon-emergent transportation by a stretcher van (T2005).You asked the Plan to pre-approvestretcher van transport. You say that the service is medically necessary.The Plan denied your request. The Plan says the service requested is not covered by the member's benefit plan under any circumstances.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 routine transportation when, but this benefit does not cover transportation by stretcher or by ambulance. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Specifically, your request for transport by a stretcher van is not a covered service under your benefit plan.Therefore, we decided that the Plan does not have to pre-approvenon-emergent transportation by a stretcher van (T2005).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided.

You asked the Plan to pay for inpatient hospital care. You say that these services were medically necessary.The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 


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 inpatient hospital care. Our reviewer says that out of network post-emergency care is not medically necessary. Our physician reviewer found that the enrollee was stable and appropriate for ambulance transport with monitoring to a Plan facility for observation/admission services after the emergency room evaluation on August 8, 2020. The post-stabilization care services, were not medically necessary or reasonable. The review has determined that the treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to not pay forthe nuclear medicine services provided on June 8, 2020.You asked the Plan to not pay forthe nuclear medicine services. You say that the Department of Veterans Affairs should pay this claim.The Plan denied your request. The Plan says they are your primary payer.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. The rules also 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 $350 for nuclear medicine services.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has paid the claim as primary payer and has charged you a cost share of $350 for the nuclear medicine services. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan processed theclaim correctly for the nuclear medicine services provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings, prophylaxis, and panoramic x-ray provided on 
September 11, 2020, by an OON provider. 
 
You asked the Plan to pay for the bitewings, prophylaxis, and panoramic x-ray. You say that a Plan 
representative gave you this provider and made the appointment for you. The Plan denied your request. The 
Plan says these services were rendered by an OON provider. The Plan also says that there are in-network 
providers that can appropriately care for you. 
 
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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
bitewings, prophylaxis, and panoramic x-ray provided on September 11, 2020, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care (99222) provided.

You asked the Plan to pay for inpatient hospital care. You say that you should not be penalized for delays in the receipt of information from the providing facility.The Plan denied your request. The Plan says rules for payment have not been met.

The Plan follows Medicare rules. The rules say that claims for services furnished, must be filed no later than one calendar year after the date of service.

The record shows that a claim for inpatient hospital care was not filed until September 18, 2020. 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 inpatient hospital care (99222) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings,and prophylaxis provided on September 15, 2020 by an OON provider.You asked the Plan to pay forthe periodic oral evaluation, bitewings, and prophylaxis. You say that the salesperson offering the Plan assured you that $1,500 per year was available.The Plan denied your request. The Plan says the total $122.00 amount applied correctly as the member liability. The Plan also says that cost sharing is a contractual obligation under the plan and cannot be waived.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, you are responsible forthe difference between the billed amount and allowed amount.Therefore, we decided that the Plan does not have to pay forthe periodic oral evaluation, bitewings, and prophylaxis provided on September 15, 2020 by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe first intraoral periapical x-ray (D0220) provided on July 29, 2020.You asked the Plan to pay forthe first intraoral periapical x-ray. You say that this service was denied due to incorrect billing. You also say that the office refuses to correct the code.The Plan denied your request. The Plan says this service is not a covered benefit under your dental plan.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 pay forthe first intraoral periapical x-ray (D0220) provided on July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea gel mattress overlay.You asked the Plan to pre-approvethe mattress overlay. You say that this is medically necessary.The Plan denied your request. The Plan says there are no respiratory conditions that keep you from lying flat.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 mattress overlay. Our reviewer says that the requested mattress overlay is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that you are completely immobile, cannot independently make changes in body position significant enough to alleviate pressure or has any stage pressure ulcer on the trunk or pelvis and impaired nutritional status,fecal or urinary incontinence, altered sensory perception, or compromised circulatory status. The coverage criteria for a gel mattress overlay per  Local Coverage Determination (LCD): Pressure Reducing Support Surfaces -Group 1 (L33830) have not been met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the mattress overlay have not been met.Therefore, we decided that the Plan does not have to pre-approvea gel mattress overlay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services rendered from July 19, 2020 to July 22, 2020.
You asked the Plan to waive the copayment for these services. You say that you were wrongly admitted to the hospital. The Plan denied your request. The Plan says the copayment was 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 $260 copayment per day for days 1-7 for a covered inpatient stay during a benefit period.
Review of the file shows that you received three days of inpatient hospital services from July 19, 2020 to July 22, 2020. You were not assessed a copayment for your date of discharge on July 22, 2020. You have been asked to pay a $260 copayment per day for these services, for a total of $780. These services fall within the covered inpatient stay during a benefit period 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 inpatient hospital services rendered from July 19, 2020 to July 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe colonoscopy provided on August 1, 2019.You asked the Plan to waive the copayment forthe colonoscopy. You say that you will not be paying this bill because the colonoscopy was inconclusive. 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 each Medicare-covered in-network ambulatory surgical center service. You have been asked to pay a $250 copayment for the colonoscopy. The colonoscopy falls within "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 forthe colonoscopy provided on August 1, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay forthe assistant surgeon services rendered on June 11, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. ThePlan says that the -AS modifier is not allowed for codes 57265, 57283, and 58262.The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 2, the payment restriction for assistants at surgery does not apply and the assistant surgeon services will be paid. In this case, you billed assistant surgery services for CPT code 57265, 57283, and 58262. The Medicare Fee Schedule Database contains a surgical indicator of 2 for this procedure. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pay forthe assistant surgeon services rendered on June 11, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair. 
 
You asked the Plan to pre-approve a power wheelchair. You say that your current chair is seven years old. The 
Plan denied your request. The Plan says you  can get assistance with a manual wheelchair at your assisted 
living facility. 
 
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 patients 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 a power wheelchair. Our physician 
reviewer found that the documentation indicates you have a personal mobility deficit, and that this deficit 
impairs participation in MRADLs. There is no objective physical neuromuscular exam of the upper or lower 
extremities indicating that your mobility deficit cannot be helped by the use of a walker, manual wheelchair, or 
current power wheelchair. The documentation is not clear that you can safely operate the requested wheelchair 
given your history of seizures and cognitive impairment. Therefore, the requested power wheelchair is not 
medically reasonable and 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 a power wheelchair have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power wheelchair.
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 IRF care is medically necessary.The Plan denied your request. The Plan says rules for IRF care have 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 the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. Finally, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fortransportation of portable x-ray equipment and personnel to the nursing home and setup provided on October 14, 2019.You asked the Plan to pay forthe transportation of portable x-ray equipment and personnel to the nursing home (R0070) and setup (Q0092). You say that the Plan should pay this claim.The Plan denied your request. The Plan says in this place of service the claim is not separately reimbursable.The Plan must follow Medicare rules. Medicare rules say that the technical component of radiology services in a SNF, during a covered stay, are not separately payable.We find that the transportationand set up costs are subject to consolidated billing. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel to the nursing home (R0070) and setup (Q0092) have not been met.Therefore, we decided that the Plan does not have to pay fortransportation of portable x-ray equipment and personnel to the nursing home and setup provided on October 14, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex Superion Device for the enrollee.You asked the Plan to pre-approvethese services. You say that these services are medically necessary.The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.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 requested services are not considered medically reasonable and necessary in this case. 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. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion indicating that a DEXA scan has demonstrated and no osteoporosis in this patient. Superion indirect lumbar decompression would not be considered the standard of care for the enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex Superion Device for the enrollee.