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

We decided that the Plan does not have to pre-approve Superion interspinous spacer.
You asked the Plan to pre-approve Superion interspinous spacer. 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 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 Superion interspinous spacer. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the enrollee has back pain. The requested spacer is experimental. More
research is needed to show safety and efficacy of the device. Therefore, the enrollee does 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 Superion interspinous spacer have not been met. Therefore, we decided that the
Plan does not have to pre-approve Superion interspinous spacer.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99284) provided January 3, 2020.
You asked the Plan to pay for the emergency visit. You say that please reprocess the claim and approve payment for the emergency service provided. The Plan denied your request. The Plan says the provider must bill the primary group health plan before billing the Plan.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan is secondary to the primary carrier. As the secondary insurer, the Plan cannot be held responsible for the emergency visit until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99284) provided January 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) of the cervical spine
(72156) provided on July 7, 2020.
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 submitted documentation supports that
one unit for CPT code 72156 was previously approved and paid. There is no additional documentation
supporting an additional study was provided and denied.
The Plan must follow Medicare rules. Medicare rules say that services must be medically necessary and
verified in the submitted physician documentation.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this service have not been met. Specifically, CPT code 72156 originally billed was approved and
paid for by the Plan on July 23, 2020. The documentation provided does not indicate that an additional study
for this service was performed on the date in question. Therefore, we decided that the Plan does not have to pay
for the magnetic resonance imaging (MRI) of the cervical spine (72156) provided on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lead wires rendered on September 11, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that replacement of lead wires (A4557) more often than every twelvemonths would rarely be reasonable and necessary.We looked at the file and Medicare rules. The services at issue are lead wires for a TENS unit. The file shows that the TENS unit with lead wires was rendered less than twelvemonths from the date of service at issue on March 11, 2020. 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 pay forthe lead wires rendered onSeptember 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from June 7, 2020, to
June 9, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the inpatient hospital care. You say that the care provided was medically
necessary. The Plan denied your request. The Plan says the inpatient hospital care was unauthorized poststabilization
care.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient hospital care. Our reviewer
says that the inpatient hospital care was not medically reasonable and necessary. Our physician reviewer found
the review indicates that the enrollee was stable enough to have been transferred to a Plan facility for inpatient
care rather than to an OON facility. The enrollee was admitted to the hospital in "Stable" condition in no
distress". At this time, the enrollee was stable for ambulance transport with monitoring to a Plan facility. All
inpatient care provided after 5:11pm on June 7, 2020, through transfer on June 9, 2020, was not needed on an
emergent basis. The treating physician did not document (in the physician notes, on a form, or in an order) that
the patient was not stable for transfer on any dates of service.
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 inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for the inpatient hospital care provided from June 7, 2020, to June 9, 2020 by an out -
of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services received on September 4, 2020.
You asked the Plan to pay for the services. You say that these tests were ordered by your PCP. The Plan denied your request. The Plan says that diagnostic tests that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. The laboratory services were referred by a contract provider - your PCP. The file does not show that the Plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for laboratory services received on September 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that you did not want to go to the hospital due to COVID-19.The Plandenied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 28, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for progressive lens (V2781) and frames (V2020) provided on
September 11, 2020.
You asked the Plan to pay for progressive lens and frames. You say that the service should be covered The Plan
denied your request. The Plan says they have paid the maximum amount covered by your plan for this service
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services with a $175 maximum allowance per year.
We looked at the file and the Plan's rules. You have exhausted your maximum allowance for eyewear. Based
on this information, we decided that the Plan's rules for coverage of progressive lens and frames have not been
met. Specifically, it is the responsibility of the member to pay any cost over the Plan's allowable maximum.
Therefore, we decided that the Plan does not have to pay for progressive lens (V2781) and frames (V2020)
provided on September 11, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Insertion of Interlaminar/Interspinous Process
Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process
Stabilization/Distraction Device (22870).
You asked the Plan to pre-approve the Vertiflex Superion implantation procedure. You say that the surgery will
enable a better life as far as mobility is concerned. The Plan denied your request. The Plan says the peer
reviewed medical literature does not show that the procedures improve long term health outcomes.
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 Vertiflex Superion implantation
procedure. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the spacer remains experimental. More research is needed
to show safety and efficacy. There is no documented spinal instability. Hardware not needed.
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 Vertiflex Superion implantation procedure have not been met. Therefore, we
decided that the Plan does not have to pre-approve Insertion of Interlaminar/Interspinous Process
Stabilization/Distraction Device (22869) and Insertion of Interlaminar/Interspinous Process
Stabilization/Distraction Device (22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of
head or brain provided on May 4, 2019.
You asked the Plan to waive the copayment for the CT scan of head and brain. You say that you would like this
copayment waived. The Plan denied your request. The Plan says the copayment applied correctly in this case.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100
copayment for diagnostic radiology.
You have been asked to pay a $100 copayment for the CT scan of head and brain. The service provided falls
within the diagnostic radiology 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 copayment for
the computed tomography (CT) scan of head or brain provided on May 4, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on June 22, 2020.You asked the Plan to waive the copayment foran emergency room visit. You say that you never had to pay for this before. You say that you were never notified of this being changed. The Plan denied your request. The Plan says the correct copayment 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 $90 copayment for emergency care/in-network. You have been asked to pay a $90 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care/in-network benefit category. This means thatyou 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 copayment foran emergency room visit provided by a participating provider on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
September 25, 2020.
You asked the Plan to pay for the dental service. You say that you have not received any services since you
joined your plan. You say that you understood that an annual exam and cleaning would be covered. You also
say that you have not exceeded the frequency limitation which was cited in the denial. The Plan denied your
request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan also says that
the frequency limit has 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, the frequency limit of 1 comprehensive
oral evaluation every 3 plan years has been exceeded. The record shows that the Plan paid for a comprehensive
oral evaluation that you received on November 6, 2019. Therefore, we decided that the Plan does not have to
pay for the comprehensive oral evaluation (D0150) provided on September 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says you would not be able to perform 3 hours of therapy daily 5 times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are living at home. You are having trouble with ambulation due to knee and hip pain. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is no reasonable expectation that you 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forlow dose computed tomography (LDCT) (G0297) provided on June 12, 2020.You asked the Plan to pay forLDCT. You say that the service is medically necessary.The Plan denied your request. The Plan says there was no indication the patient was or is a smoker.The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary.Therefore, we decided that the Plan does not have to pay forlow dose computed tomography (LDCT) (G0297) provided on June 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plandoes not haveto pay forambulance services provided to the enrollee on January 19, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysambulance services billed with a GY modifier isdoes not meet the definition of any Medicare benefitThe 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 the denied codes is:A0425:Ground mileage, per statute mileA0427:Ambulance service, advanced life support, emergency transport, level 1 (als 1 -emergency)We find that the denied codes are not supported in the medical record. Specifically,these codes are reported with a GY modifier, which means they are meant to be statutorily not covered. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forambulance services provided to the enrollee on January 19, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced knee and foot feature for a prosthesis.
You asked the Plan to pre-approve advanced features. The Plan denied your request. The Plan says the use of an assistive device is not consistent with a K3 ambulator.
The Plan follows Medicare rules. Medicare rules say that lower limb prostheses are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve advanced features. Our physician reviewer found that the enrollee requires assistance to ambulate. He uses a cane/walker, exhibits pain to hips, and poor endurance. He needs a hydraulic to help him safely navigate his house and community. Without the hydraulic he would have jeopardized mobility due to being on his feet 3-5 hours daily. The requested K3 knee and foot is not medically necessary as the progress notes do not support that the enrollee's functional level is a K3, with demands for prosthetic utilization beyond simple locomotion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of advanced features have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced knee and foot feature for a prosthesis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network
(OON) provider on July 21, 2020.
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 office visit (99214) rendered by the out of network (OON) provider on July 21,
2020.