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

 We decided that the Plan does not have to pre-approve the laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar (CPT code 63042), laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar (CPT code 63047), arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (22612), arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (22614), arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) (22842), and autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) (20936), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says it is noted the enrollee is not having claudication symptoms (legs feel heavy and weak after walking longer distances), has not failed three (3) months of non-operative therapy, and symptoms are not rapidly progressing.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria not met. More conservative measures are needed such as physical therapy (PT) for back pain.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the services (CPT code(s): 63042), 63047, 22612, 22614, 22842, and 20936), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to reimburse you for eyeglasses provided on July 28, 2021.  You asked the Plan to reimburse you for eyeglasses. You say that you were not aware you had to use in-network providers. You say that you did not call in as you just printed the hearing and vision form online. The Plan denied your request. The Plan says for routine eyewear and routine eye exam, you must use the Plan's vision network provider.  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.   We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by the Plan's vision network provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse you for eyeglasses provided on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of stabilization device (22869) provided on September 28, 2021.  You asked the Plan to pay for the insertion of stabilization device (22869). You say that procedure code 22869 is a payable code by Medicare. You say that the notes show this was not experimental and the claim should be reprocessed for payment. The Plan denied your request. The Plan says experimental or investigational services are not covered.  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 pay for the insertion of stabilization device (22869). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interspinous process distraction devices are experimental. More research is needed to show safety and efficacy.  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 insertion of stabilization device (22869) have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of stabilization device (22869) provided on September 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an electrocardiogram (EKG) provided on September 27, 2021.  You asked the Plan to waive the copayment for an EKG. You say that you should not be charged a copayment for an EKG because you pay one for the office visit. The Plan denied your request. The Plan says the proper copayment was applied for this service.  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 copayment for Medicare-covered non-radiological diagnostic services. The total amount charged was $14.34 which is less than the copayment amount of $20. Therefore, the total copayment amount allowed was $14.34.  You have been asked to pay a $14.34 copayment for an EKG. An EKG 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 an electrocardiogram (EKG) provided on September 27, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a selective catheter placement procedure.  You asked the Plan to pre-approve the requested services. You say that the enrollee cannot walk and has end stage renal disease. The Plan denied your request. The Plan says very little clinical information was received about the enrollee's illness.  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. In this case, there are insufficient medical records to show that the coverage criteria for the requested services have been met. The file shows that the Plan made multiple attempts to obtain additional information, without success. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a selective catheter placement procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on February 17, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for an office visit provided on February 17, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the under incision procedures on the lens of the eye (66821) rendered on July 12, 2021.  You asked the Plan to waive the copayment for the under incision procedures on the lens of the eye. You say that you are concerned about being charged more than what the hospital quoted you. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $365 copayment for outpatient surgery, including services provided at hospital outpatient facilities.    You have been asked to pay a $365 copayment for the under incision procedures on the lens of the eye. The under incision procedures on the lens of the eye 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 the under incision procedures on the lens of the eye (66821) rendered on July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an X-ray provided on September 23, 2021.  You asked the Plan to waive the copayment for an X-ray. You say that you had to have the X-ray repeated and feel that you should not owe the second 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 $35 copayment for X-rays.   You have been asked to pay a $35 copayment for an X-ray. An X-ray 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 an X-ray provided on September 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the notes do not show a medical need to control the power options through the joystick, the power options can be controlled using their own switches, and these switches can be made any size without asking for a separate request.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Since the power tilt and recline and leg elevation feature includes a switch control and the enrollee is able to operate the switch controller, the upgraded electronic (expandable controller) is not needed. The enrollee does not need to operate these power options through the joystick. Therefore, we decided that the Plan does not have to pre-approve the electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services (80048) rendered on September 8, 2021.  You asked the Plan to waive the copayment for laboratory services. You say that due to illness, you are required to have the laboratory test completed each year and there should not be an additional charge. You also say that this should be included in the annual wellness exam. The Plan denied your request. The Plan says you were charged the correct cost sharing 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 $10 copayment for other Medicare covered laboratory tests that are not FIT tests.   You have been asked to pay $8.41, which is less than the $10 copayment for laboratory services. Laboratory services 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 laboratory services (80048) rendered on September 8, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Visual Field testing.  You asked the Plan to pre-approve Visual Field testing. The Plan denied your request. The Plan says the enrollee does not meet the Medicare local coverage criteria (L34615).  The Plan follows Medicare rules. Medicare rules say that initial evaluation for macular degeneration related to central vision loss or has experienced such loss resulting in vision measured at or below 20/70.  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 Visual Field testing. Our reviewer says that Visual Field testing is not medically necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has non-exudative macular degeneration and has already had an initial evaluation. The record does not indicate that the enrollee has experienced new onset loss resulting in vision measured at or below 20/70. The record does not indicate that testing at frequent intervals is medically reasonable and necessary, as defined by Medicare rules, for the enrollee's specific medical condition at this time. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Visual Field testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Visual Field testing.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the orthopedic footwear (CPT code L3217).  You asked the Plan to pre-approve the orthopedic footwear. You say that you need the shoes due to having suffered from Polio as a child and are now having post-polio syndrome. You state you are having trouble walking. The Plan denied your request. The Plan says you are not wearing a brace attached to a shoe.  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 the orthopedic footwear (CPT code L3217).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on August 26, 2021.  You asked the Plan to pay for the dental services. You say that your last visit was in December 2020. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 3 plan years. The Plan says that 1 complete series x-ray is covered every 3 plan years. The Plan also says that these frequency limits have 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 and the services are listed as covered, the frequency limits have been exceeded.   The record shows that the Plan paid for a complete oral comprehensive oral evaluation and a complete series x-ray that you received on September 28, 2020. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), and complete series x-ray (D0210) provided on August 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from February 12, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that you caught the coronavirus and have to be quarantined for ten (10) days, so the treatment had to stop. You state you need more days to finish the treatment. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services. The Plan states while you may benefit from continuing physical, occupational, and speech therapy, the records do not support the need for daily therapy on an inpatient basis.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from February 12, 2022, forward.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a cardiovascular stress test provided on September 16, 2021.  You asked the Plan to waive the copayment for the stress test. You say that you were recommended for a stress test to received clearance for cataract surgery. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $150 copayment for each advanced imaging service, including stress tests.   You have been asked to pay a $150 copayment for the stress test. The stress test 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 cardiovascular stress test provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the supply allowance for therapeutic CGM, includes all supplies and accessories (CPT code K0553NU).  You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that you are not using an insulin injection three or more times. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve the supply allowance for therapeutic CGM, includes all supplies and accessories (CPT code K0553NU).