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

We decided that the Plan does not have to pay for an office visit (99214) provided on April 26, 2021, by out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 for an office visit (99214) provided on April 26, 2021, by out-of-network (OON) provider.
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 IRF care is medically necessary for the enrollee's condition. 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 in the Medicare rules section. 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 that the patient was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. In conclusion, 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) for teeth #30 and 31.
You asked the Plan to pre-approve the dental services. You say that you feel that this is a necessary treatment. You also say that you do not have any other options. The Plan denied your request. The Plan says implants are not covered services.
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, implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for teeth #30 and 31.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650) and implantation neurostimulator electrode) (CPT code L8680), for the enrollee.
You asked the Plan to pre-approve the service. You say that you are under the belief the service denied based on a misunderstanding regarding the enrollee's condition and medical necessity. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show the enrollee does not have a condition for which this treatment 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 service. Our physician reviewer found the applicable LCD states that this service is only to be considered a service of "last resort" when other treatment options have been tried/failed/exhausted. The information provided for review indicates a longstanding history of low back pain. However, the notes did not indicate that the enrollee had undergone any form of surgery for their low back. Nor was it clearly indicated that the enrollee's condition was not otherwise amenable to surgical intervention. In as much the requirements of the LCD would not have 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650) and implantation neurostimulator electrode) (CPT code L8680), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor (CGM) (K0553, K0554) provided on December 2, 2020.
You asked the Plan to pay for a Freestyle Libre CGM. You say that this is supported in the records. The Plan denied your request. The Plan says the records don't show this was necessary.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pay for a Freestyle Libre continuous glucose monitor (CGM) (K0553, K0554) provided on December 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve suction pump, home model, portable or stationary, electric, any type, for use with external urine management system (CPT code K1006).
You asked the Plan to pre-approve the device. You say that you have urine burns from wearing pads and diapers twenty-four (24) hours a day. The Plan denied your request. The Plan says this device (the Purewick Urine Collection System) is an upgraded device. The Plan states an upgrade is an item that exceeds the legitimate medical needs of a person. The Plan states upgrades primarily provide comfort or convenience.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Medicare says that items are covered if they are reasonable and necessary to serve the intended purpose. This device (the Purewick Urine Collection System) is an upgraded device. An upgrade is an item that exceeds the legitimate medical needs of a person. Upgrades primarily provide comfort or convenience. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve suction pump, home model, portable or stationary, electric, any type, for use with external urine management system (CPT code K1006).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve the destruction of benign lesions other than skin tags or cutaneous
vascular lesions (17110).
You asked the Plan to pre-approve the procedure. You say that that the medical records provided support the
necessity of the services in dispute. The Plan denied your request. The Plan says that the medical necessity
criteria have not been met.
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 procedure. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found Our physician reviewer found seborrheic keratosis is a cosmetic problem unless they show
features requiring removal/destruction as described in LCD L33445
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 procedure have been met. Therefore, we decided that the Plan has to preapprove
the destruction of benign lesions other than skin tags or cutaneous vascular lesions (17110).
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on February 23, 2021.

You asked the Plan to pay for the radiologic examination, chest; single view (71045). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the radiology services are not eligible for benefits according to SNF Consolidated Billing guidelines.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

The member was in a Skilled Nursing Facility setting on this date of service, therefore we find the Medicare rule for payment of this claim has not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on February 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on April 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member's primary care physician did not refer these services.
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 for lab work provided on April 7, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible applied to ambulance services you received on February 4, 2021.
You asked the Plan to waive the deductible applied to the ambulance services. You say that you do not understand why you have to pay both a deductible and a copayment for this service. The Plan denied your request. The Plan says you were assessed this deductible correctly. You had not yet met your deductible when you received these services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $250 deductible that applies to ambulance services and a $50 copayment once the deductible is met. You had not yet met your deductible when you received these ambulance services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $250 deductible that applies to ambulance services and that after that deductible is met, you pay a $50 copayment. This cost sharing is a contractual obligation that had not been met at the time the ambulance services was received on February 4, 2021.
Therefore, we decided that the Plan does not have to waive the deductible applied to ambulance services you received on February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ambulance services provided on October
22, 2020, and hospital observation services provided on October 23, 2020.
You asked the Plan to waive the copayments for the ambulance services and the hospital observation services.
You say that the enrollee was admitted to the hospital, so the ambulance copayment should be waived. The
Plan denied your request. The Plan says these copayments were charged correctly. The Plan says that the
enrollee was kept in observation at the hospital and they were not admitted as an inpatient.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees
must pay a $275 copayment for ambulance services and a $275 copayment for hospital observation services.
The enrollee has been asked to pay a $275 copayment for the ambulance services and a $275 copayment for the
hospital observation services. Records show that the enrollee was kept in observation status in the hospital and
was not formally admitted as an inpatient. Observation is an outpatient status, so the ambulance copayment
was applied correctly. This means that the enrollee has been asked to pay the correct amount based on the
contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in
the Plan. Therefore, we decided that the Plan does not have to waive the copayments for ambulance services
provided on October 22, 2020, and hospital observation services provided on October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved and you are no longer a threat to yourself or others.
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 hospital services. Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you were not showing any dangerousness to self or others, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. You were cooperative and compliant with medication. 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 as you do not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (88360) provided on December 17, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 88360 is part of an edit pair with procedure code 88361. Procedure code 88361 is a column one code, and procedure code 88360 is a column two code. Procedure code 88361 has been paid on this claim, which means that procedure code 88360 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (88360) provided on December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device.
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 indication for coverage is not met due to contraindications.
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 your medical condition. Our physician reviewer found that your 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 Vertiflex Superion Interspinous device.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.

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 that the patient is a 68-year-old male with multiple sclerosis related spastic paraplegia who was admitted to the current acute care hospital with thigh pain and spasms for 2 weeks. The patient appears to be currently improving and more stable requiring only short-term additional acute care services for basic wound care and ongoing IV antibiotics which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility.There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary as transfer at this time would not provide a clinical advantage. Transfer to a lower level of care may be considered when treatment has completed. 

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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on April 21, 2021.
You asked the Plan to waive the coinsurance for chemotherapy. You say that you were told that switching to a different drug would save you money. You state that the drug costs $10,000 less but you are only saving $47 and are unhappy that your cost-sharing responsibility isn't less. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 Part B prescription drugs. You received chemotherapy on April 21, 2021. The total allowed amount is $2,750.16 and 20% of that is $550.03. You have been asked to pay the total coinsurance amount of $550.03 for chemotherapy. Chemotherapy falls within the Medicare Part B prescription drugs 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 chemotherapy provided on April 21, 2021.