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

 We decided that the Plan does not have to pre-approve insertion of a lumbar interspinous decompression device for the enrollee.  

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the requested device is considered experimental.  

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5.   

This enrollee has multiple degrees of spinal stenosis, none of which are at FDA indicated levels of "moderate" spinal stenosis. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There is no documentation of the enrollee's height, weight or body mass index. There is no discussion of scoliosis of the lumbar spine with no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. 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 Vertiflex Superion interspinous decompression device (unspecified level) 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a lumbar interspinous decompression device for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95819) provided on December 11, 2020.  You asked the Plan to pay for code 95819. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 95819.  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 95819 is Electroencephalogram (EEG), including recording awake and asleep.  We find that CPT code 95819 is not supported in the medical record. Specifically, the records show that the EEG included drowsiness, not sleep. There is a more appropriate code for the description of the services provided. Based on this information, we decided that Medicare rules for coverage of code 95819 have not been met. Therefore, we decided that the Plan does not have to pay for the Electroencephalogram (EEG) (95819) provided on December 11, 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 August 18, 2021.

  You asked the Plan to pay for the comprehensive oral evaluation. You say that you needed to see a new dentist because you were due for your dental exam and cleaning and had moved over two hours away from your previous dentist. The Plan denied your request. The Plan says benefits for this service have been satisfied and the frequency limitation 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, comprehensive oral evaluation (D0150) is limited to one procedure code every three years. The record shows that you received a comprehensive oral evaluation (D0150) on November 11, 2019 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on August 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric services. You say that the enrollee's discharge would result in harm to himself and rapid readmission. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this level of care.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 30, 2021, with Major Depressive Disorder, Single Episode, Unspecified, Poly Substance Use Disorder (Alcohol and Heroin) and Acute Grief. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This enrollee was compliant and cooperative with treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the patient's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of January 6, 2022, forward and could have been treated in a lesser restrictive 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 inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740) for tooth # 14 provided on August 17, 2021.  You asked the Plan to pay for the dental services. You say that you received a bad crown from your previous dentist. You say that you had a toothache. You say that there was an infection under the crown that was previously placed. You also say that you feel you should not be responsible for this charge since the work was done improperly to begin with. The Plan denied your request. The Plan says crowns are covered once per tooth every 5 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 and crowns are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a crown for tooth # 14 that you received on February 3, 2021. Therefore, we decided that the Plan does not have to pay for the crown (D2740) for tooth # 14 provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested Vertiflex Superion interspinous decompression spacer at L3-4 is not medically reasonable or necessary. 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 Vertiflex Superion interspinous decompression spacer at L3-4 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the advance care planning services (99497) provided on March 16, 2021, through March 18, 2021.  You asked the Plan to pay for the advanced care planning. 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 service 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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate   We find that CPT code 99497 is not supported in the record. Specifically, the documentation submitted does not include the amount of time spent rendering the advance acre planning services. Based on this information, we decided that Medicare rules for coverage of the advanced care planning have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services (99497) provided on March 16, 2021, through March 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for image guided fluid collection (10030) performed January 6, 2021.  

You asked the Plan to pay for the procedure. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support an additional unit of this service.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT code 10030 is not supported in the medical record. Specifically, one unit of this service was already paid. No additional documentation was provided to support an additional unit. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pay for image guided fluid collection (10030) performed January 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for medical and surgical services provided from March 17, 2021, to April 17, 2021.

You asked the Plan to pay for the medical and surgical services. You say that these services were medically necessary, and you believed this surgery was authorized. The Plan denied your request. The Plan says although the procedure was authorized at the surgery center, you were not authorized to use this specific doctor. This specific doctor has opted out of Medicare and therefore services with this provider cannot be covered.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. 

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for medical and surgical services provided from March 17, 2021, to April 17, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the Skilled Nursing Facility services billed with Patient Driven Payment Model (PDPM) code GEPF1 and provided on March 5, 2021, through March 25, 2021.  You asked the Plan to pay for the Skilled Nursing Facility services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says that the PDPM code billed is not the code that was authorized.  The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Skilled Nursing Facility services have been met. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the Plan did not submit a compelling denial rationale in this case. The claim was denied due to lack of authorization for the SNF services. However, the Plan has attested that the SNF services were authorized with a HIPPS code that was calculated at the time that the approval was requested. Based on how the HIPPS code is calculated, however, it is not reasonable to expect or require that the code requested for authorization be the code that is billed. The HIPPS code billed must correspond to the enrollee's actual condition and the services actually rendered during the statement period of the claim. It would therefore be expected that the billed code would differ from a code that was estimated prior to the services being rendered. The Plan has not made any argument that any of the digits of the billed HIPPS code are incorrect or not supported, only that the code, as a whole, was not approved. We find that this denial of payment has not been substantiated. Therefore, we decided that the Plan has to pay for the Skilled Nursing Facility services billed with Patient Driven Payment Model (PDPM) code GEPF1 and provided on March 5, 2021, through March 25, 2021.   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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvic x-rays (72170) provided on August 23, 2021.

You asked the Plan to pay for the pelvic x-rays. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support that multiple services were rendered.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pelvic x-rays have not been met. Specifically, the documentation submitted does not support that additional x-ray interpretations were rendered. The documentation supports one unit of 72170. Therefore, we decided that the Plan does not have to pay for the pelvic x-rays (72170) provided on August 23, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ultrasound study of arm and leg arteries (93922) provided on August 10, 2021.  You asked the Plan to waive the copayment for the ultrasound. You say that you do not understand this cost. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Outpatient radiological diagnostic services, such as ultrasounds, require a $110 copayment. Your cost is lower in this case, because the Plan's allowed amount (discounted rate) for this particular ultrasound is lower than the required copayment, so you are being asked to pay the lesser 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 $110 copayment for Medicare-covered radiological diagnostic services, not including x-rays.   You have been asked to pay a $103.47 copayment for the ultrasound. An ultrasound falls within the Medicare-covered radiological diagnostic services, not including x-rays 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 ultrasound study of arm and leg arteries (93922) provided on August 10, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room visit (99282) provided on June 3, 2021.

  You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.  

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 $75 copayment for Medicare-covered emergency room visits.   

You have been asked to pay a $75 copayment for the Medicare-covered emergency room visit provided. 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 emergency room visit (99282) provided on June 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve shoe inserts described by code L3000.  You asked the Plan to pre-approve these services. You say that you have diabetes and need new orthotics. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that inserts and other shoe modifications (including L3000) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace.  We looked at the file and Medicare rules. The file shows that the requested shoe inserts are described by code L3000 (foot, insert, removable, molded to patient model, 'UCB' type, Berkeley shell, each). These inserts are covered when they are a medically necessary part of a covered brace. The file shows that you are requesting shoe inserts for the treatment of diabetic foot disease. Inserts for that condition are described by a different procedure code and may be covered if requested under that code. The inserts described by code L3000 are not covered, as you are not requesting them as part of a brace. Therefore, we decided that the Plan does not have to pre-approve shoe inserts described by code L3000.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of a leadless pacemaker (33274). 

 You asked the Plan to pre-approve the insertion of a leadless pacemaker. You say that this is critical to your daily function. The Plan denied your request. The Plan says the criteria for coverage have not been met. 

 The Plan must follow Medicare rules. Medicare rules say that a leadless pacemaker will be covered for enrollees that are enrolled in a Medicare-approved study.   

We looked at the file and Medicare rules. The file indicates that you are currently not enrolled in a Medicare-approved study. Based on this information, we decided that Medicare rules for coverage of the insertion of a leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a leadless pacemaker (33274).