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

We decided that the Plan does not have to pre-approve the Intracept procedure for levels L3-L4.

You asked the Plan to pre-approve the Intracept procedure. You say that it is felt that this procedure is medically necessary. The Plan denied your request. The Plan says there is not sufficient support for this procedure in the peer-reviewed literature.

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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this 79-year-old female was being treated for spondylosis without myelopathy or radiculopathy, lumbar region; other intervertebral disc degeneration, lumbar region. She presented with persistent low back pain. There was decreased range of motion and intact neurological exam. However, detailed documentation is not evident regarding any recent exams having been performed for the lower back. The most recent exam was on 1/27/21 for subjective complaints of low back pain and 9/9/20 to include any objective findings of the lumbar spine. Surgical intervention is not indicated without an updated exam to corroborate ongoing subjective complaints as well as objective deficits. Furthermore, the provided MRI of the lumbar spine is not indicative of Modic changes at the requested surgical levels. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Intracept at L3 and L4 is 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for levels L3-L4.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 72170 provided on July 7, 2021.

You asked the Plan to pay for the x-ray 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 separately payable.

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 72170 for the x-ray services is a column II code to column I code 73502. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 72170 provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (power scooter).  You asked the Plan to pre-approve power scooter. You say that you have multiple sclerosis (MS) and have a hard time walking. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because there is no documentation indicating that you have limitations participating in mobility-related activities of daily living (MRADLs) at home and a licensed medical professional has not performed an evaluation to see if you meet criteria for a power operated vehicle.  The Plan follows Medicare rules. Medicare rules state that a power operated vehicle (POV) may be covered if certain clinical criteria are met.  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 power scooter. Our reviewer says that you do not meet the Medicare criteria for the requested power operated vehicle (POV). Our physician reviewer found the documentation indicates that you have a mobility deficit, but this deficit does not significantly impair mobility-related activities of daily living (MRADLs) in the home. You are independent with a cane for short walking distances and have full strength in your upper extremities. You are independent in MRADLs in the home. You are noted to have had right rotator cuff injury in the past but have full strength and range of motion in the upper extremities. It is not clear that you would be unable to propel a properly configured manual wheelchair.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (POV) (power scooter).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided on September 10, 2020.
You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for hospital services provided on September 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you
received from June 2, 2021, to June 25, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you believed the Plan was going
to extend your 'free' days by three days because the social worker at the facility never told you otherwise. The
Plan denied your request. The Plan says you were charged this copayment 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 $0
copayment per day for days 1-20, and a $184 copayment per day for days 21-100 for skilled nursing facility
services.
Records show that you were in the SNF for 23 days. You were not charged a copayment for the first 20 days.
For the remaining three days, you were charged a $184 copayment per day, for a total of $552. This is in
accordance with your contract. There is no provision in your contract for a waiver of this copayment for any
reason. 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 skilled nursing facility (SNF) services you
received from June 2, 2021, to June 25, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electric bariatric wheelchair.
You asked the Plan to pre-approve an electric bariatric wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have an electric wheelchair. You received an electric wheelchair in April 2021. Your current wheelchair serves the same purpose as the requested electric wheelchair. Therefore, we decided that the Plan does not have to pre-approve an electric bariatric wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance and copayment for tooth extractions (D7140, D7210) and other non-covered dental services (D5899, D5130, D7310) provided on May 4, 2021.
You asked the Plan to waive the coinsurance and copayment for the dental services. You say that the Plan sent paperwork to the provider saying they were in network, so you continued to get the dental work done. You say you paid a sum out of pocket and thought it would be your only payment but then received a bill for services the Plan says are not payable by the Plan. The Plan denied your request. The Plan says the request for payment of codes D5899, D5130, and D7310 is denied due to being non-covered services. The Plan says you are responsible for cost-shares listed in your EOC when treated by an in-network provider. However, the Plan also says you are responsible for the full cost if you get a service not listed.
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 certain comprehensive dental services, including extractions, after you meet your $50 deductible. You have been asked to pay a cost-share of $2,676.20 for services which fall within the Dental Services benefit category. You are responsible for a 20% coinsurance on extractions after you pay your $50 deductible. You are also responsible for the full cost of non-covered services. Extractions:
(D7140): Allowed Amount $73  20% = $14.60
(D7210): Allowed Amount $139 - $50 deductible = $89
$89 (Amount due after deductible)  20% = $17.80 + $50 deductible = $67.80
(D7210  6): Allowed Amount $139  20% = $27.80  6 services = $166.80
Non-Covered Services:
(D5899): $580
(D5130): $1,279
(D7310  2): $284  2 services = $568
Total Charges: $14.60 + $67.80 + $166.80 + $580 + $1,279 + $568 = $2,676.20
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 and copayment for tooth extractions (D7140, D7210) and other non-covered dental services (D5899, D5130, D7310) provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for enrollees who has failed conservative treatment and do not have instability to indicate that fusion is the appropriate treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because more studies are needed to show that Intracept is safe and effective.

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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the Food & Drug Administration (FDA) indications for Intracept, it is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care and is also accompanied by features consistent with Type 1 or Type 2 Modic changes. The requested levels are not all within the FDA indicated levels. Additionally, there are multiple plausible pathologic sources of significant pain generation. Notable is that exam dated September 8, 2021 did not demonstrate a full return of symptoms from the August 11, 2021 radiofrequency ablation (RFA). There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital admission on April 2,
2021.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the enrollee fell during
the hospital stay and health abruptly declined thereafter, ultimately resulting in the enrollee's passing. You say
the enrollee's estate should not be responsible for the copayment on April 2, 2021, because the services
performed were related to the fall. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $300 copayment for each day of Inpatient Hospital Care for the first five days.
The enrollee has been asked to pay a $300 copayment for the inpatient hospital stay, which falls within the
Inpatient Hospital Care benefit category. This means that the enrollee has been asked to pay the correct amount
based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay
upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an
inpatient hospital admission on April 2, 2021.
Your complaint about potential quality of care concerns during the enrollee's hospital stay is not a valid appeal
for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare
does not permit us to make a decision about these types of complaints. The Plan noted in the records sent to
Maximus that this complaint is under review. Please contact the Plan for further information or assistance with
this grievance
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the porcelain fused to high noble metal crown (D2750) provided on June 30, 2021.  You asked the Plan to pay for the dental service. You say that you were experiencing sharp pain when you bite down. You say that you had a large filling with decay. You also say that the crown was medically necessary. The Plan denied your request. The Plan says porcelain fused high noble metal crown is not listed as a covered service.  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 crown is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the porcelain fused to high noble metal crown (D2750) provided on June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on July 16, 2021.
You asked the Plan to waive the copayment for an epidural injection. You say that you were told that you would only owe a $100 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received an epidural injection at an outpatient hospital facility on July 16, 2021. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment.
You have been asked to pay a $275 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an epidural injection provided on July 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services 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 pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of mixed
connective tissue disease. There is no documentation of failed conservative treatments. There is no record of x-
ray results documenting osteoarthritis. The drug is not Food and Drug Administration (FDA)-approved for the
enrollee's condition. The Euflexxa is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit, the injection procedure, the
dexamethasone sodium phosphate injection, the foot strapping service, and the foot x-ray you received from a
podiatrist on July 22, 2021.
You asked the Plan to waive the deductible for the podiatry services. You say that you would have expected
only a copayment when you saw this doctor. The Plan denied your request. The Plan says you had not yet met
your deductible at the time you received these services.
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 $500 deductible which applies to podiatry services.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which
applies to podiatry services. This cost sharing is a contractual obligation that had not been met at the time the
podiatry services were received on July 22, 2021. Therefore, we decided that the Plan does not have to waive
the deductible for the office visit, the injection procedure, the dexamethasone sodium phosphate injection, the
foot strapping service, and the foot x-ray you received from a podiatrist on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transit kit option for a wheelchair.
You asked the Plan to pre-approve a transit kit option. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate
and needed for use inside the home.
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not
have to pre-approve a transit kit option for a wheelchair
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a breast ultrasound provided on July 22, 2021.

You asked the Plan to waive the copayment for a breast ultrasound. You say that you have never been charged in the past and disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $30 copayment for each X-ray. 

You have been asked to pay a $30 copayment for a breast ultrasound. A breast ultrasound falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for a breast ultrasound provided on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).  You asked the Plan to pre-approve Vertiflex procedure. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).