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

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that the spacer would provide significant
clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says medical
studies haven't proven that the device is helpful for the enrollee's 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 the requested services. Our physician
reviewer found that the requested device is considered experimental. More research is needed to determine its
efficacy. Therefore, the requested service is not medically reasonable and 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 an interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 20, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 and the referring provider in this case are not network providers 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 laboratory services provided on December 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit received on October 18, 2019.You asked the Plan to waive the copayment forthe visit. You say that you were supposed to receive a shot, but didn't receive it that day.The Plan denied your request. The Plan says the copaymentwas applied correctly in this case.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 $15 copayment for specialist office visits. You have been asked to pay a $15 copayment for the visit. The visit falls within the specialist office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing isa 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 foran office visit received on October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95909, 95885, 95813) provided on December 10, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 95909 is "Nerve conduction studies; 5-6 studies". The CPT Code Manual definition of code 95885 is "Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 95813 is "Electroencephalogram (EEG) extended monitoring; greater than 1 hour". 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 services. Our reviewer says that the use of CPT code 95909, 95885, 95813, is not supported by the records provided. Our physician reviewer found that the documentation does not clearly report that Nerve Conduction studies were performed per the NCCI policy manual. The documentation also does not report that an EMG was performed with nerve conduction, amplitude and latency/velocity study. Lastly, there is no documentation showing that an EEG extended monitoring of greater than one hour was performed. 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 pay for the services (95909, 95885, 95813) provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the requested services. You say that previous lumbar facet blocks resulted in better than 80% temporary improvement in enrollee's pain levels. The Plan denied your request. The Plan says the records do not show the pain is localized to the enrollee's neck or back.
The Plan follows Medicare rules. Medicare rules say that facet joint radiofrequency neurotomy 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 chronic low back pain. The pain is described as radicular. There is no documentation of physical therapy, chiropractic care, or a home exercise program because the enrollee refused. A prior facet injection procedure increased pain. The request is for RFA of the medial branch blocks. The request does not meet the coverage criteria. The pain is radicular and there is no documentation of conservative therapy. Therefore, the request is considered 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 radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99356) provided from September 5, 2019 to September 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
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 99356 is "Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)". 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 use of CPT code 99356 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation to corroborate that "Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service)" was performed from September 5, 2019, to September 12, 2019, therefore this service cannot be validated. 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 the services (CPT 99356) provided from September 5, 2019 to September 12, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you continue to be a fall risk, and lacks the strength to have a successful recovery at home. The Plan denied your request. The Plan says you do not need intensive therapy, or an intensive team for care.
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 physician reviewer found that you are medically stable from debility, with no recent neurological or Orthopedic events. You are at contact guard assist to minimal assist for activities of daily living. There is no evidence of complex medical issues that require monitoring by an inpatient rehab physician three times per week, or need for acute rehab nursing care. While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the chest/abdomen/pelvis/neck/orbits for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is needed to rule out a relapse of lymphoma, or a different primary cancer. The Plan denied your request. The Plan says this imaging request is unable to be approved.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the high SUV in rectum requires sigmoidoscopy, not CT imaging. There is no clinical indication for this scan, per the NCCN guidelines. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the chest/abdomen/pelvis/neck/orbits for the enrollee.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the fluid circulating cold pad with pump and a positioning pillow provided on October 8, 2019.
You asked the Plan to pay for the fluid circulating cold pad with pump and a positioning pillow. You say that the items were medically necessary after your surgery. The Plan denied your request. The Plan says that a positioning pillow is not primarily medical in nature and a cold pad is considered not reasonable and necessary by Medicare.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for the fluid circulating cold pad with pump and a positioning pillow by a contract provider. The file does not show that the Plan provided notice that the fluid circulating cold pad with pump and a positioning pillow would not be covered. Under Medicare rules, this means the fluid circulating cold pad with pump and a positioning pillow is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the fluid circulating cold pad with pump and a positioning pillow provided on October 8, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoutpatient physical therapy visits.You asked the Plan to pre-approvephysical therapy. You say that the enrollee is unable to stand without support.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because these services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration ofthe enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as a specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapies and continues to have moderate deficits. The ongoing requested therapy is not appropriate without evidence of a skilled need. The enrollee has been educated in a home exercise program. The enrollee's functional level and documented deficits do not need the unique skills of a professional therapist tosafely and effectively provide treatment. Services do not need to be safely and effectively performed only by a therapist or under the supervision of a therapist. The requested services are not part of a maintenance program. We looked at this physician'sreview, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveoutpatient physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the radiation therapy rendered from March 1, 2019 to March 14, 2019.
You asked the Plan to waive the coinsurance for these services. You say that you had met your maximum out of pocket amount. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for radiation therapy at an outpatient hospital.
Review of the file shows that you received radiation therapy from March 1, 2019 to March 14, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $1,047.40. These services fall within the radiation therapy at an outpatient hospital 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. The file shows that you had met $5,571.06 of your $6,7000 maximum out of pocket at the time this claim was processed. Therefore, we decided that the Plan does not have to waive the coinsurance for the radiation therapy rendered from March 1, 2019 to March 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on February 4, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The Plan must follow Medicare rules. The rules say that post-operative services are included in the global surgical package. We looked at the file and Medicare rules. The provider submitted a claim for procedure code 99212 (office visit) within the global surgical period for previously billed code 20611 (arthrocentesis). Payment for these services is included in the global surgical package. Therefore, we decided that the Plan does not have to pay for the office visit rendered on February 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services 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 any days after June 12, 2020 are not covered, due to the enrollee reaching the 100 day maximum.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from October 14, 2019 to June 4, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysongoing needs can be met in a lower level of care, such as IRF or SNF.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 long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include intravenous antibiotics, neurologic monitoring, surveillance laboratory studies, complex wound care, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral exam (D0140), the extraction (D7210), and
the bone replacement graft for ridge preservation (D7953) provided from December 30, 2019 to January 17,
2020.
You asked the Plan to pay for the dental services. You say that you were referred to the provider in this case.
You also say that you did not understand what the provider meant when they said that they were opted-out of
Medicare. The Plan denied your request. The Plan says the provider in this case has opted-out of Medicare
participation. The Plan also says dental services that you receive from providers that do not participate in the
Medicare program cannot be paid.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider in
this case. This provider has opted out of the Medicare program. The file shows that the provider entered into a
private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for the
limited oral exam (D0140), the extraction (D7210), and the bone replacement graft for ridge preservation
(D7953) provided from December 30, 2019 to January 17, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown. a mandibular partial denture (D5214).
You asked the Plan to pre-approve the crown. the mandibular partial denture. You say that the dentures you
received in 2016 never fit. You say that you have something below the gum that prevents them from fitting.
You say that you cannot eat, have to chew with your gums, and want coverage for a replacement. The Plan
denied your request. The Plan says the enrollee had denture services covered within the last 60 months and the
benefit cannot be used again until April 2021.
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 benefit for dentures is limited to
once every 60 months. The records show that you received coverage for dentures on April 6, 2016. This means
that your benefit for dentures is currently exhausted. Therefore, we decided that the Plan does not have to preapprove
the crown. a mandibular partial denture (D5214).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray (71045) provided January 21, 2020.
You asked the Plan to pay for the x-ray. You say that the service was medically necessary. The Plan denied
your request. The Plan says the service has a bundled relationship with another service already billed.
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, we have confirmed that code 71045
has a Column I/Column II relationship with code 74022 and cannot be paid as billed. This code cannot be paid
as a separate line item. 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 chest x-ray (71045) provided January 21, 2020.