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

We decided that the Plan does not have to pay for the assistant surgeon services provided during insertion of intervertebral biomechanical device(s) services coded 22854 and the vertebral corpectomy services coded 63082 provided on October 26, 2020.
You asked the Plan to pay for the insertion of intervertebral biomechanical device(s) and the vertebral corpectomy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 22854 and 63082 are not supported in the medical record. Specifically, the operative report did not include documentation of an insertion of intervertebral biomechanical device(s) (synthetic cage,
mesh), with integral anterior instrumentation for device anchoring (screws, flanges) when performed, to
vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with
interbody arthrodesis, for each contiguous defect (listed separately in addition to code for primary
procedure); therefore, code 22854 cannot be verified. The operative report did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using an anterior approach with decompression of spinal cord and/or nerve root(s), for each additional cervical segment (listed separately in addition to code for primary procedure); therefore, code 63082 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the insertion of intervertebral biomechanical device(s) and the vertebral corpectomy services have not been met. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services provided during insertion of intervertebral biomechanical device(s) services coded 22854 and the vertebral corpectomy services coded 63082 provided on October 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you require a shower chair for your condition. The Plan denied your request. The Plan says although this would help you, this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the glasses purchased on November 30, 2020 which included deluxe frames (V2025) and anti-reflective lens coating (V2750).
You asked the Plan to pay for the deluxe frames and anti-reflective tint. You say that you received these glasses as a result of a recent cataract surgery and therefore they should be covered. The Plan denied your request. The Plan says anti-reflective tint and deluxe frames are not covered by Medicare; only basic lenses and frames are covered. The Plan has issued partial payment to the provider to cover the cost of basic frames and lenses issued post-cataract surgery, minus your coinsurance amount, however the remainder of the cost is your responsibility.
We looked at the file and the rules. Medicare specifically states that only standard frames are covered. Deluxe frames can be covered up to the cost of standard frames, but the remainder of the cost is the enrollee's responsibility. The Plan has indicated that they have paid 80% of the cost of the basic frame expense and left you with 20% of the Medicare-covered portion as outlined in your contract. The extra cost for the deluxe frames is your responsibility.
Anti-reflective coating on lenses can only be covered by Medicare when they are provided due to medical necessity. The provider issued stated that the anti-reflective tints were provided out of personal preference, and not medical necessity. Therefore, the anti-reflective tint is excluded from Medicare coverage and you are responsible for the full cost of the lens upgrade. There is also documentation that your provider informed you that the deluxe frames and lens coating were not covered services and would require your payment out-of-pocket.
Documentation shows that the Plan has paid for the post-cataract surgery eyewear as outlined in the contract. Your contract with the Plan clearly says that you must pay 20% coinsurance of the total cost of Medicare-covered eyeglasses or contact lenses after each cataract surgery. The Plan has paid for the basic lenses (V2100) and the standard frames (V2020) at 80% of the cost. You are responsible for your 20% coinsurance payment for the cost of the basic eyewear, plus the cost of the excluded (non-Medicare covered) deluxe frames and lens upgrades.
Based on this information, we decided that the Plan has correctly paid for the glasses as outlined in the contract, and the deluxe frames and anti-reflective coating are not covered by Medicare. Therefore, we decided that the Plan does not have to pay the full cost for the glasses purchased on November 30, 2020 which included deluxe frames (V2025) and anti-reflective lens coating (V2750).
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 admission to a SNF. You say that the requested SNF admission is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee has no complex wound care or other skilled nursing need. The enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. Skilled nursing or therapy services are not required on a daily basis or as a practical matter on an inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of admission to a SNF 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (64999) provided August 27, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
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 code 64999 is not supported in the medical record. Specifically, per the National Correct Coding Initiative Policy Manual, Chapter 2 Anesthesia Services, an Anesthesiologist must bill an anesthesia service when a surgical service is billed. No anesthesia service (00100 - 01999) was billed for this service. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (64999) provided August 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided October 12, 2020.
You asked the Plan to pay for the PET scan. You say that the service was medically necessary. The Plan denied your request. The Plan says a valid diagnosis code was not 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 code 78815 is not supported in the medical record. Specifically, C55 was billed as the primary diagnosis code. This is not listed as a valid diagnosis code for this procedure. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for a Positron Emission Tomography (PET) scan (78815) provided October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided October 13, 2020.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the services 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 99152 is Moderate sedation services provided by the
same physician or other qualified health care professional performing the diagnostic or therapeutic service that
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of
the patient's level of consciousness and physiological status.
We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not show that
an observer was present. Based on this information, we decided that Medicare rules for coverage of the
sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation
services (99152) provided October 13, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy provided on September 25, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the colonoscopy. You say that your mother is being harassed by the doctor's office for payment. This process has been extremely overwhelming. She was misguided on every level of patient care. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 colonoscopy provided on September 25, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring provided on October 30, 2020.
You asked the Plan to pay for continuous intraoperative neurophysiology monitoring (95940). You say that the Plan should pay this claim. The Plan denied your request. The Plan says two claims were billed for the same service for the same enrollee.
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 continuous intraoperative neurophysiology monitoring (95940) has a bundled relationship with code 38724 and cannot be paid as billed. Therefore, we decided that the Plan does not have to pay for continuous intraoperative neurophysiology monitoring provided on October 30, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient services provided by a participating provider on December 15, 2020.
You asked the Plan to waive the coinsurance for outpatient services. You say that you do not agree with this. You say that you have never paid this before. The Plan denied your request. The Plan says the correct coinsurance has been 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 outpatient hospital observation. You have been asked to pay a 20% coinsurance of the allowed amount for outpatient services. The total allowed amount is $1,428.26. The total amount you are being asked to pay is $285.65 ($1,428.26 x 20% = $285.65). Outpatient services fall within the outpatient hospital observation 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 outpatient services provided by a participating provider on December 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a personal emergency response system.
You asked the Plan to pre-approve a personal emergency response system. You say that you currently have Lifeline installed and you still need it and you have diabetes. The Plan denied your request. The Plan says the plan has confirmed with the primary care physician that there is no history of falls on record therefore, the enrollee does 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 looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a personal emergency response system have not been met. Therefore, we decided that the Plan does not have to pre-approve a personal emergency response system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation provided on December 10, 2020.
You asked the Plan to pay for the periodic oral evaluation. You say that you would like this service to be covered. The Plan denied your request. The Plan says benefits for this service had been satisfied and frequency limitations had been exceeded.
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, periodic oral exam is limited to two procedures per calendar year. The record shows that you received periodic oral evaluations on June 10, 2020, and July 7, 2020, and your periodic oral exams benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation provided on December 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that this request should be approved based on your medical condition. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychological testing provided on October 16, 2020, and October 17, 2020.
You asked the Plan to pay for the psychological testing. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 psychological testing. 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 psychological testing provided on October 16, 2020, and October 17, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your request. The Plan says that the doctor's notes should say how the imaging will change treatment.
The Plan must follow Medicare rules. Medicare rules say that cardiovascular nuclear imaging is covered under 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 the imaging. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's EKG has a right bundle branch block. In this case, the enrollee had a syncopal episode that is considered possibly of cardiac origin. In addition, the enrollee has a bundle branch block on the electrocardiogram. The elements of the local coverage determination are satisfied. The requested service is recommended. 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 imaging have been met. Therefore, we decided that the Plan has to pre-approve myocardial perfusion imaging for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on December 9, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you needed this service and believe it should be covered. The Plan denied your request. The Plan says this service is not covered.
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 problem focused limited oral evaluation provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ketamine infusion services provided on March 4, 2020.
You asked the Plan to pay for the Ketamine infusion services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are 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 pay for the Ketamine infusion services. Our reviewer says that the documentation does not support that the Ketamine infusion was medically reasonable or necessary. Our physician reviewer found in July 2019; the International Anesthesia Research Society published the results of a systematic literature review which compiled the results from seven randomized controlled trials evaluating the long-term effectiveness of ketamine infusion for the treatment of pain. In total, the seven trials that were evaluated included 211 patients with three types of pain: neuropathic, mixed and nonneuropathic. Three of the seven studies reported significant analgesic benefit with ketamine, with a small analgesic effect that persisted for up to two weeks post-infusion. There was no difference in pain relief based on pain classification. The results suggested but did not establish, enhanced pain relief with higher doses of ketamine and in patients with complex regional pain syndrome. The analysis also concluded that additional studies enrolling a larger population of patients are needed in order to determine the efficacy of ketamine for chronic pain syndrome. The review has determined that the items/services at issue in this case are 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 Ketamine infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the Ketamine infusion services provided on March 4, 2020.