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

We decided that the Plan does not have to pre-approve the back procedure (Intracept Intraosseous Nerve
Ablation System) (CPT code 22899), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has chronic pain that affects their life
on a daily basis. You state the enrollee has tried non-operative treatment and it has not work. You state the
doctor feels this procedure is the enrollee's option for pain relief. The Plan denied your request. The Plan says
the services are 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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Intracept procedure remains experimental for the treatment of low back pain. More research
is needed to show safety and efficacy of the procedure.
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 pre-approve the back procedure (Intracept Intraosseous Nerve Ablation System) (CPT code 22899), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator, electrical, non-invasive, spinal
applications (CPT code E0748).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the Medicare rule are only met if you are high risk for pseudoarthrosis from a prior
failed spine fusion and you have had at least a three (3) level fusion. The Plan state you have had only two (2)
levels; therefore, you do not meet the criteria.
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 DME. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the available documentation does not support that you have failed spinal fusion where a
minimum of nine (9) months has elapsed since the last surgery, a multilevel spinal fusion surgery involving
three (3) or more vertebrae, or a history of a previously failed spinal fusion at the same site.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve osteogenesis stimulator, electrical, non-invasive, spinal applications (CPT code E0748).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Herceptin.
You asked the Plan to pre-approve Herceptin. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Herceptin. Our reviewer says that Herceptin is medically reasonable and necessary in this case. Our physician reviewer found that Herceptin (Trastuzumab) is FDA-approved for the treatment of HER2 overexpressing breast cancer. In light of the lower toxicity and a more favorable health-related quality of life profile, Herceptin (Trastuzumab) monotherapy can be considered an adjuvant therapy option for selected older patients. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Herceptin have been met. Therefore, we decided that the Plan has to pre-approve Herceptin.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) received March 29, 2021.
You asked the Plan to pay for the pulp vitality tests. You say that this procedure should be covered as part of
the root canal. The Plan denied your request. The Plan says the requested service is not covered under your
supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp
vitality tests (D0460) received March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray and extraction provided on February 10, 2021.
You asked the Plan to pay more for the limited oral evaluation, intraoral x-ray and extraction. You submitted your bill for review. You say that a refund should be sent. The Plan denied your request. The Plan says the claim processed correctly.
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, your contract says that you pay 50% coinsurance for an emergency diagnostic exam, 50% coinsurance for an intraoral x-ray and 55% coinsurance for an extraction from an out-of-network provider. You may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider.
Service
Billed Amount
Allowed Amount
Difference of Billed & Allowed Amount
Coinsurance
Member Liability
Limited Oral Evaluation
$44
$35
$9
$17.50
$26.50
Intraoral X-Ray
$18
$13
$5
$6.50
$11.50
Extraction
$143
$66
$77
$36.30
$113.30
TOTAL:
$151.30
Therefore, we decided that the Plan does not have to pay more for the limited oral evaluation, intraoral x-ray and extraction provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
services coded 95941 provided on March 16, 2021.
You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring services. You say that
you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are
not payable 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.
In this case, the CPT Code Manual definition of code 95941 is continuous intraoperative neurophysiology
monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while
in the operating room, per hour (List separately in addition to code for primary procedure).
We find that CPT code 95941 is not supported in the medical record. Specifically, this code has a status code of
"I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment of these services. Based on this information, we decided that Medicare rules for
coverage of the continuous intraoperative neurophysiology monitoring services have not been met. Therefore,
we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring
services coded 95941 provided on March 16, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on April 7, 2021.
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 procedure code 71045 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 71045 (chest x-ray) and 74022 (abdomen x-ray). Code
71045 is a column II code with a modifier indicator of 1 when billed with column I code 74022.
Code 71045 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided
that the Plan does not have to pay for the chest x-ray rendered on April 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the patient is stable after chronic obstructive pulmonary disease exacerbation with no new medical problems, has no documented nursing needs and he is at high functional level and does not need daily skilled therapies in an inpatient setting. Hence the SNF admission is not medically necessary with daily therapies in an inpatient setting. Their rebab needs can be met with home health care with therapies at home. If discharge at home is not feasible, their care needs will have to be met in a custodial care and do not warrant an admission to a SNF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
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 you could become bed ridden and need constant monitoring for breathing. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in another setting.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for coronary artery bypass grafting. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 pay for the comprehensive periodontal evaluation (D0180) received
January 28, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the requested services
should be covered by the Plan. The Plan denied your request. The Plan says the requested service is not
covered under your supplemental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
comprehensive periodontal evaluation (D0180) received January 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

Explanation of decision
We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and
prophylaxis provided on April 7, 2021 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, and prophylaxis. You say that you
were not advised that this treating provider is OON. The Plan denied your request. The Plan says these services
were received OON. The Plan also says that you are responsible for 100% of the cost for services received
OON.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the
cost for dental services rendered by an OON provider.
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, and
prophylaxis provided on April 7, 2021 by an 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 the records provided support the need for IRF care. The Plan denied your request. The Plan says the records do not support a continued IRF stay. The Plan says that the services needed can safely be received at a different setting.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
The enrollee was admitted for a craniotomy for traumatic subdural and intracranial hemorrhage. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. You appear to be at your new baseline. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of your condition. Your
care needs at this point are custodial and, as a practical matter, can be provided at 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided April 5, 2021.
You asked the Plan to pay for the orthosis. You say that please see attached documentation. The enrollee requested services utilizing access to telemedicine from the physician of their choice in an effort to address COVID-19 concerns. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for thoracic-lumbar-sacral orthosis (L0457) provided April 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87798, 87486, 87581) provided on June 17, 2020.
You asked the Plan to pay for laboratory services. You say that this testing cannot be performed in the office. 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 testing at issue was billed with POS 81 for an independent laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87798, 87486, 87581) provided on June 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator, with integrated electrocardiogram analysis (Zoll Life Vest) (K0606), provided on January 13, 2021.
You asked the Plan to waive the coinsurance for the Zoll Life Vest. You say that you should not be held responsible for the coinsurance because your doctor could not perform a procedure due to CoViD and you were not told by the DME provider that you would have a cost-share. The Plan denied your request. The Plan says the cost share 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 advanced durable medical equipment.
You have been asked to pay a 20% coinsurance for the Zoll Life Vest. This item falls within the durable medical equipment and related supplies 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 the automatic external defibrillator, with integrated electrocardiogram analysis (Zoll Life Vest) (K0606), provided on January 13, 2021.