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

We decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the radiology report documented no nerve root compression and no central canal or foraminal stenosis.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating that there has been a failure of four weeks of conservative therapy. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.

You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not medically necessary.

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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with low back pain. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. The request is not medically 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).

You asked the Plan to pre-approve Vertiflex. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental/investigational. More research is needed to show its safety and efficacy. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Monovisc (J7327).

You asked the Plan to pre-approve Monovisc. You say that the enrollee received a Cortisone injection with only 1 week of pain relief. You also say that you were told if the Cortisone failed the enrollee would be approved for Monovisc. The Plan denied your request. The Plan says this medication does not meet criteria because it is not being supplied by the provider's office.

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 Monovisc (J7327).

Benefits for Monovisc may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for hearing aids provided on
March 30, 2021.

You asked the Plan to pay an additional amount for hearing aids. You say that $500 should have been applied to the claim for your hearing aids. The Plan denied your request. The Plan says $150 of your hearing aid benefit was used on June 29, 2020 for a right hearing aid receiver/sound wire repair. As stated in the Evidence of Coverage, you have a total of a $500 limit for hearing aids every three years.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan paid $150 of your hearing aid benefit on June 29, 2020 and $350 for the hearing aids provided on March 30, 2021. The file shows the hearing aid benefit is every three years. Therefore, we decided that the Plan does not have to pay an additional amount for hearing aids provided on March 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an external defibrillator provided December 18, 2020 to January 18, 2021.
You asked the Plan to waive the coinsurance for the external defibrillator. You say that the defibrillator was provided from a network provider and should be covered. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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 Durable Medical Equipment. You have been asked to pay a 20% coinsurance for the external defibrilator. The external defibrilator falls within the Durable Medical Equipment 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 an external defibrillator provided December 18, 2020 to January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a talking thermometer (E1399).

You asked the Plan to pre-approve the talking thermometer. You say that the claim should be paid. The Plan denied your request. The Plan says the denial is upheld because the talking thermometer is not considered durable medical equipment and it is an item that is available for the general public.

The Plan must follow Medicare rules. Medicare rules say that equipment which is primarily and customarily used for a nonmedical purpose may not be considered "medical" equipment for which payment can be made under the medical insurance program. This is true even though the item has some medically related use. Neither Medicare nor your Plan consider first-aid or precautionary-type equipment as durable medical equipment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the talking thermometer have not been met. Therefore, we decided that the Plan does not have to pre-approve a talking thermometer (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ambulatory infusion pump (E0781) and supplies associated with it (A4221, A4222).

You asked the Plan to pre-approve the infusion pump. You say that the infusion pump is necessary. The Plan denied your request. The Plan says there is no clinical documentation to support the medical necessity of the requested DME supplies.

The Plan must follow Medicare rules. Medicare rules say that an infusion pump and supplies described by codes E0779, E0780, E0781, and E0791 is covered for indications: Administration of deferoxamine, Administration of chemotherapy, Administration of morphine, or Administration of continuous subcutaneous insulin. These were not indicated in the records; saline is not a covered indication. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the infusion pump have not been met. Therefore, we decided that the Plan does not have to pre-approve an ambulatory infusion pump (E0781) and supplies associated with it (A4221, A4222).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (99285, G8428, 93010) provided March 26, 2021.

You asked the Plan to pay for the emergency room services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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. 

We find that CPT codes 99285, G8428, & 93010 are not supported in the medical record. Specifically, the record shows the enrollee was incarcerated at the time the services were rendered. In this case, services meeting the exceptions for payment must be billed with the "QJ" modifier. The required modifier was not included. Based on this information, we decided that Medicare rules for coverage of the emergency room services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (99285, G8428, 93010) provided March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015), ophthalmological medical examination and evaluation (92004), and the ophthalmic biometry (92136) rendered by the out-of-network (OON) provider on February 8, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered 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 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 eye refraction (92015), ophthalmological
medical examination and evaluation (92004), and the ophthalmic biometry (92136) rendered by the out-ofnetwork
(OON) provider on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on January 18, 2021.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 out of network physician services provided to the enrollee on January 18, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on March 5, 2021.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits. Services rendered by non-participating providers require prior authorization as outlined in the enrollee's Evidence of Coverage.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on March 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for home health/hospice aide services provided from
February 1, 2021, through February 25, 2021.
You asked the Plan to pay for home health/hospice aide services. The Plan denied your request. The Plan says Hospice care is paid for through original Medicare not by your health plan. We have confirmed with the provider that they billed and were paid by Medicare for these services.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for home health/hospice aide services provided from
February 1, 2021, through February 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an enhanced steering performance unit (K0108), a seat
elevation system (E2300), and a replacement cover wheelchair cushion (E2619).
You asked the Plan to pre-approve an enhanced steering performance unit, a seat elevation system, and a
replacement cover wheelchair cushion. You say that you would like the Plan to reconsider their denial. The
Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
We looked at the file and Medicare rules. In this case, the requested enhanced steering performance unit
(K0108) is already included with the requested expandable controller (E2377). The enhanced steering
performance unit should not be requested separately.
Medicare specifically excludes coverage of power seat elevation systems coded as E2300.
Furthermore, the requested replacement cover wheelchair cushion (E2619) cannot be covered with initial issue.
The requested skin protection seat cushion (E2607) and back cushion (E2620) already come with covers.
Therefore, we decided that the Plan does not have to pre-approve an enhanced steering performance unit
(K0108), a seat elevation system (E2300), and a replacement cover wheelchair cushion (E2619).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.
You asked the Plan to pre-approve medial branch blocks. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are only covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve medial branch blocks. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found you have chronic neck and low back pain. You take Lyrica, Voltaren Percocet and MS Contin for pain. You have had physical therapy. You had an excellent prior radiofrequency ablation result and your physician wants to repeat the diagnostic blocks instead of repeating the radiofrequency ablation. This is not in keeping with the standard algorthm of care. Therefore, you do not meet criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 you appear to be unstable and still requires short-term acute care treatment which can be safely provided at the current facility. You do not require services at the LTACH that are no already available at the current facility.
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. Specifically, medically necessary services are being obtained at your current level of care and there are no additional services offered at the LTACH. This means admission into a LTACH is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the destructions of skin growths provided on May 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the destructions of skin growths. You say that you believed you could see network providers without a referral. The Plan denied your request. The Plan says the provider is out-of-network.

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 the destructions of skin growths provided on May 4, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia (00902) rendered by the out-of-network (OON) provider on March 17, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.

The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the anesthesia (00902) rendered by the out-of-network (OON) provider on March 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have
been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). You have tolerated inpatient
rehabilitation services and continues to improve with daily skilled nursing and/or skilled therapy services and
could benefit from continued services at the current 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 the SNF care have not been met. Specifically, there are no services offered at a
SNF that are not offered at your current facility. This means SNF care is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.