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

We decided that the Plan does not have to pre-approve the Vertiflex interspinous decompression spacer procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that the enrollee needs this to treat lumbar spinal stenosis with neurogenic claudication. The Plan denied your request. The Plan says that the requested procedure is not indicated for those with severe spinal 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. Our physician reviewer found that the enrollee's condition does not meet criteria for these services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous decompression spacer procedure for the enrollee
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional homemaker service hours.
You asked the Plan to pre-approve the additional hours. You say that you do not know why your hours have been reduced. The Plan denied your request. The Plan says the time provided should be enough to help with activities of daily living.
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 additional hours. Our reviewer says that the requested additional hours are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is medically stable without any recent hospitalizations or medical complications. The approved 106.5 hours of monthly homemaker services allow for appropriate support and care. The documentation does not support that the additional hours are needed to provide adequate support.
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 additional hours have not been met. Therefore, we decided that the Plan does not have to pre-approve additional homemaker service hours
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 15, 2021, to March 16, 2021.

You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled services on the dates of service in this case.

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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF care have not been met. Specifically, the file does not indicate that the enrollee required daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 15, 2021, to March 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) rendered by an out-of-network (OON) provider from January 8, 2021, through January 22, 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. You are 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 psychotherapy services (90837) rendered by an out-of-network (OON) provider from January 8, 2021, through January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the skin lesion removal procedure you had at your dermatologist's office on May 12, 2021.

You asked the Plan to waive the deductible for the skin lesion removal procedure. You say that you don't think you should have to pay this bill because the doctor only spent 10 minutes with you and he didn't know what the mark on your leg was. The Plan denied your request. The Plan says you had not yet met your deductible when you had this procedure, so the deductible was assessed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible which applies to surgical procedures in a specialist's office. 

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to surgical procedures in a specialist's office. This cost sharing is a contractual obligation that had not been met at the time the skin lesion removal procedure was received on May 12, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the skin lesion removal procedure you had at your dermatologist's office on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the nebulizer rendered on July 29, 2020.
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 that the claim was not filed timely.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the claim was not filed timely; however, the file shows that the request was received within one year of the date of service. The Plan has not provided any documentation to support that the services are not payable. Therefore, we decided that the Plan has to pay for the nebulizer rendered on July 29, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantation of neurostimulator electrodes (64581)
and an insertion of a neurostimulator pulse generator (64590).
You asked the Plan to pre-approve an implantation of neurostimulator electrodes and an insertion of a
neurostimulator pulse generator. You say that the requested procedure will support the enrollee's maximum
function for bladder control. The Plan denied your request. The Plan says rules for coverage have not been met
because the enrollee has not trialed any conservative therapy.
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 an implantation of neurostimulator
electrodes and an insertion of a neurostimulator pulse generator. Our reviewer says that the requested services
are not considered medically reasonable and necessary in this case. Our physician reviewer found that the
records do not show that the enrollee has tried any conservative medical therapy. Additionally, the enrollee has
neurogenic bladder due to Multiple Sclerosis per the records. The safety and effectiveness of sacral nerve
stimulation has not been established in people with this condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an implantation of neurostimulator electrodes and an insertion of a
neurostimulator pulse generator have not been met. Therefore, we decided that the Plan does not have to preapprove
an implantation of neurostimulator electrodes (64581) and an insertion of a neurostimulator pulse
generator (64590).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from March 12, 2019, to March 13, 2019.
You asked the Plan to pay for the home health services. You say that you have not received any payments on this overdue claim. You say that the claim was submitted in a timely manner. You also say that no remittance advice was received from your office. The Plan denied your request. The Plan says the claim was received after 12-months. The Plan also says that claims received after 12 months are not covered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the home health services was not filed until June 2, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the home health services provided from March 12, 2019, to March 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the topical application of fluoride varnish (D1206), intraoral - complete series of radiographic images (D0210), unspecified preventive procedure, by report (D1999), prophylaxis - adult (D1110) and comprehensive oral evaluation - new or established patient (D0150) provided March 11, 2021 and crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950) and unspecified preventive procedure, by report (D1999) provided April 28, 2021.

You asked the Plan to provide additional payment for the fluoride varnish, intraoral x-rays, unspecified preventative procedure, dental cleaning, comprehensive oral exam, crown and core buildup. You say that the provider told you they were in-network and you would like the claims to be processed as in-network. The Plan denied your request. The Plan says the claims 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. The Plan covers the fluoride varnish, intraoral x-rays, dental cleaning, comprehensive oral exam, crown and core buildup when the services are medically necessary and reasonable. 

We looked at the file and Medicare rules. The unspecified preventative procedure is not among those service covered under your dental benefits. The Plan provided documentation showing that they provided coverage equal to or greater than the amount explained in the Plan contract for the remaining services at issue. Your out-of-network provider may have charged you an additional amount for the difference between the Medicare payment rate for participating providers and the total cost billed by the provider. Therefore, we decided that the Plan does not have to provide additional payment for the topical application of fluoride varnish (D1206), intraoral - complete series of radiographic images (D0210), unspecified preventive procedure, by report (D1999), prophylaxis - adult (D1110) and comprehensive oral evaluation - new or established patient (D0150) provided March 11, 2021 and crown - porcelain/ceramic (D2740), core buildup, including any pins when required (D2950) and unspecified preventive procedure, by report (D1999) provided April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a nebulizer (E0570) provided on August 10, 2020.

You asked the Plan to pay for a nebulizer. You say that this was filed correctly. The Plan denied your request. The Plan says that the documentation supplied did not support adjustments.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not submitted any information about the initial denial reasoning. While the Plan has submitted a remittance advice, it does not include the date of service at issue. Without this information, the denial reasoning cannot be verified. Therefore, we decided that the Plan has to pay for a nebulizer (E0570) provided on August 10, 2020.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor testing supplies provided on March 12, 2021.
You asked the Plan to pay for the continuous glucose monitor testing supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor testing supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor testing supplies provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on March 17, 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 the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. 

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the Guardant360 panel rendered on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the abdominal lymphadenectomy and other abdominal procedure (38747 and 49999) provided on February 10, 2021.
You asked the Plan to pay for the abdominal procedures. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted 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 38747 is abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or without para-aortic and vena caval nodes (List separately in addition to code for primary procedure).
The CPT Code Manual definition of code 49999 is unlisted procedure, abdomen, peritoneum and omentum. We asked our coder 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 abdominal procedures. Our reviewer says that CPT code 38747 does not meet criteria for billing or reimbursement consideration. The medical records provided document that procedure. 48150 was also performed and does not include sufficient documentation that CPT 38747 was performed independent of 48150. Therefore, 38747 is included in procedure 48150 and should not be billed separately. Our reviewer found CPT code 49999 does not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation to validate that an Unlisted procedure, abdomen, peritoneum and omentum was performed on February 10, 2021, therefore, this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the abdominal procedures have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal lymphadenectomy and other abdominal procedure (38747 and 49999) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection.
You asked the Plan to pre-approve the requested services. You say that you are in extreme pain. The Plan
denied your request. The Plan says you do not meet Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that lumbar epidural steroid injections are only
covered under certain medical indications.
We looked at the file and Medicare rules. The records show that you previously received lumbar epidural
steroid injections on March 9, 2021, April 29, 2021, and July 14, 2021. No more than 3 injections may be
performed in a 6-month period. Based on this information, we decided that Medicare rules for coverage of the
requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a
lumbar epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on February 19, 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 the claim was not billed with a valid primary diagnosis code.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis
code.
We looked at the file and Medicare rules. The file shows that the services were not billed with a valid primary
diagnosis code. 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 for the subsequent hospital care
rendered on February 19, 2021.
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 these services are medically necessary. The Plan
denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a
lower level of care.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for shortness of breath and had
surgery for replacement of aortic valve and aortic arch. Your medical problems are stable. 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
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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.