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

We decided that the Plan has to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612) and autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (CPT Code 20937) for the enrollee.

You asked the Plan to pre-approve the services. You say that this is the most appropriate surgical care for this patient. The Plan denied your request. The Plan says that the requested service is supported when a spinal fusion surgery has been approved and the records do not show that a spinal fusion surgery has been approved for the enrollee.

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 services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is concern for further instability at L4-5 with wide laminectomy surgery only over 3 levels of the spine. There is possibly enough autogenous bone graft from the 3 level laminectomy to use the local bone only at L4-5 for fusion graft material which the surgeon should consider. The fusion portion of the surgery should be approved with consideration given to using local bone graft at the L4-5 level to prevent the surgeon's concern for postoperative iatrogenic instability and worsening back pain. Iliac Crest bone graft should only be used through a separate incision is there is not enough local bone graft from the multilevel laminectomy. The enrollee's history of severe back pain with 5 mm of L4-5 slippage and the surgeon's concern for postoperative instability with laminectomy only surgery is the compelling reason to perform the fusion 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 the services have been met. Therefore, we decided that the Plan has to pre-approve arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612) and autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (CPT Code 20937) for the enrollee.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from May 10, 2020, to May
12, 2020, by an ineligible provider.
You asked the Plan to pay for the medical services. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says they cannot pay this claim because of inactive and closed rate record.
Medicare rules say that no Medicare payment may be made to a provider for services provided by a provider
who is not eligible to take Medicare payment.
The requested provider in this case is not a Medicare provider. There are no records in the file supporting
emergency care. 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 from May 10, 2020, to May 12, 2020, by an ineligible provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require a transfer to the LTACH.

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 there is no documentation provided necessitating admission to a LTACH. Th enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer surgery for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The spacer device remains experimental. More research is needed to show safety and efficacy of the spacer device. 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-approve the Superion interspinous spacer surgery for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient mental health care hospital stay provided August 17, 2019, through August 26, 2019.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the cost-share. 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 $225 copayment per day for days 1-7 for inpatient mental health care. You have been asked to pay a total of $675 in copayments for the inpatient mental health care hospital stay. The copayment applied was $225 per day up until you hit your in-network out-of-pocket maximum of $6,700. This inpatient stay falls within the Inpatient mental health care 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 mental health care hospital stay provided August 17, 2019, through August 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the lumbar spine.
You asked the Plan to pre-approve the MRI. You say that you would like reconsideration because the MRI is medically necessary. The Plan denied your request. The Plan says there are no musculoskeletal or neurologic symptoms or signs and no evidence of trauma, malignancy, infection, congenital spinal cord/vertebral conditions, or previous spine surgery.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI. Our reviewer says that this request for MRI lumbar spine will be considered not medically necessary at this time. Our physician reviewer found the musculoskeletal and neurologic exams were noted as "normal." No radiculopathy was noted or other signs or symptoms suggestive of a red flag diagnosis. It was not noted in the provided notes as to whether or not conservative treatments were tried. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the lumbar spine.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care.

You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid for DRG 190. The Plan denied your request. The Plan says DRG 192 is more appropriate in this case.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG. DRG 190 is defined as Chronic Obstructive Pulmonary Disease, with major complications or comorbidities.

In this case, you billed the services provided with DRG 190. 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 DRG 190 is not supported in the medical records. Our physician reviewer found there was no documentation of acute on chronic respiratory failure with hypoxia. The appropriate DRG is 192.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate DRG 190. Therefore, we decided that the Plan does not have to pay for inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMems (33289). You asked the Plan to pre-approve a CardioMems. You say that the item is medically necessary. The Plan denied your request. The Plan says there is not enough studies to show the CardioMEMS device consistently improves the health of patients with this member's medical condition. 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 a CardioMems. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found the efficacy of the CardioMEMS heart failure system remains uncertain at this time; further clinical study is needed to determine the efficacy and safety of this device. 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 CardioMems have not been met. Specifically, this service is considered experimental for the member's diagnosis. This means the item is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve a CardioMems (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740). You asked the Plan to pre-approve the porcelain/ceramic crow. You say that this service is necessary. The Plan denied your request. The Plan says the benefit has been exhausted for the requested service. 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 the porcelain/ceramic crow when the services are medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. The file indicates that you last received a porcelain/ceramic crown for tooth #28 in March 2019. Therefore, the benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage of the porcelain/ceramic crow have not been met. Therefore, we decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on September 10, 2020.
You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request.
The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The service at issue was billed with POS 81 for an independent
laboratory, but the records show that the sample was not taken in a laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (G0483) provided on September 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that there no documentation that an additional protective outer surface covering is needed.

The Plan must follow Medicare rules. Medicare rules say that the protective outer surface covering system is used by a beneficiary who has special needs for protection against unusually harsh environmental situations.

We looked at the file and Medicare rules. The record does not show you are subject to harsh environmental situation. 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 an addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve.

You asked the Plan to pay for the knee orthosis (L1833RT) and suspension sleeve (L2397RT). You say that the
orthoses are medically necessary. The Plan denied your request. The Plan says there are no claims from the
ordering physician.

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 knee orthosis (L1833RT) and suspension
sleeve (L2397RT). Our reviewer says that the orthoses are not medically necessary. Our physician reviewer
found the documentation in the case file does not support that the requested knee orthosis and sleeve were
medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established
by the LCD. There is insufficient documentation of an examination of the enrollee, and there is insufficient
credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when
the base item is not covered.

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 knee orthosis (L1833RT) and suspension sleeve (L2397RT) have not been
met. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Auricular Stimulation Therapy (CPT Code 64555) and Percutaneous Implantation of Neurostimulator Electrode Array; Peripheral Nerve (L8679).
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that this is not covered by Medicare.
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 services have not been met. The following devices are listed under the Food and Drug Administration (FDA) documents as electro-acupuncture devices used for stimulation of auricular acupuncture points (CPT code 64999) and as such are non-covered. Acupuncture for stimulation of auricular points is not a covered Medicare benefit. NeuroStim system/NSS, P-Stim, ANSiStim, E-Pulse Other current or future devices when used for the procedure Auricular Peripheral Nerve Stimulation or Electro-Acupuncture, would also be considered a non-covered service. The request for Auricular Peripheral Nerve Stimulation is denied as non-covered. This service is not a covered Medicare benefit because acupuncture for auricular stimulation does not meet the definition of reasonable and necessary under Section 1862(a)(1) of the Medicare Act. Therefore, we decided that the Plan does not have to pre-approve Auricular Stimulation Therapy (CPT Code 64555) and Percutaneous Implantation of Neurostimulator Electrode Array; Peripheral Nerve (L8679).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from March 11, 2021 onward.
You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric care is correct.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our physician reviewer found it is not expected that this enrollee will improve in a reasonable period of time beyond March 11, 2021 as he is not showing any dangerousness to self or others, no auditory or visual hallucinations, and no abnormal behaviors. The enrollee was compliant with treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from March 11, 2021 onward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D6010, D6011, D6056).
You asked the Plan to pre-approve the services. You say that you need this because the plate does not stay in your mouth. The Plan denied your request. The Plan says this service is not covered under your benefit package.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D6010, D6011, D6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for deluxe lenses provided on November 10, 2020.
You asked the Plan to pay for the deluxe lenses. You say that you would like reconsideration because this is the prescription written by your surgeon. The Plan denied your request. The Plan says deluxe lenses are not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers one pair of standard glasses or contacts after each cataract surgery. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the deluxe lenses have not been met. Therefore, we decided that the Plan does not have to pay for deluxe lenses provided on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One.
You asked the Plan to pre-approve Gel-One. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Gel-One.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response, treatment with no transport (A0998) provided March 12, 2020.
You asked the Plan to pay for the ambulance response. You say that the ambulance provider did not have to transfer you, and by your husband taking you, no ambulance service was received, leaving you to pay the $250 that they changed. The Plan denied your request. The Plan says this service is 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 March 12, 2020. 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 response, treatment with no transport (A0998) provided March 12, 2020.