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

We decided that the Plan does not have to pre-approve Vertiflex Superion device.
You asked the Plan to pre-approve Vertiflex Superion device. You say that you would like plan to reconsider their denial The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has back pain. The 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 Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical assistant services provided on February 12, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this claim line was not billed in accordance with the guidelines.
The Plan follows Medicare rules. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.
In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 20985. The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. We looked at the file and Medicare rules. We find that CPT code 20985 is not supported in the medical record. Specifically, the records do not show this service was part of the surgeon's plan of care. There is no supporting documentation to show this service was a necessary part of the surgery services provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the surgical assistant services provided on February 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colectomy coded 44150 and the colonoscopy coded
45381 provided on April 9, 2021.

You asked the Plan to pay for the colectomy and the colonoscopy. 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 supported by the
documentation.

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 codes 44150 and 45381 are not supported in the medical record. Specifically, the
documentation does not support colectomy, total, abdominal, without proctectomy; with ileostomy or
ileoproctostomy. The operative report describes a laparoscopic procedure being performed for the colectomy.
There is a more appropriate code to be billed for these services rendered. The documentation does not support a
directed submucosal injection was performed during the colonoscopy billed under code 45381, Colonoscopy,
flexible; with directed submucosal injection(s), any substance; and are still needed. Based on this information,
we decided that Medicare rules for coverage of the colectomy and the colonoscopy have not been met.
Therefore, we decided that the Plan does not have to pay for the colectomy coded 44150 and the colonoscopy
coded 45381 provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on January 28, 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 procedure codes 15004, 14301, and 14302 are not supported.
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 15004 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. The definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to
code for primary procedure).
We find that CPT codes 15004, 14301, and 14302 are not supported in the medical record. Specifically, there is
no documentation of surgical preparation or creation of recipient site by excision to support code 15004. The
records show that undermining of an adjacent tissue transfer to achieve closure was performed and this does
not support codes 14301 and 14302. 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 surgical
services rendered on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI scan of the spine (72148) provided on July 12, 2021.
You asked the Plan to waive the copayment for an MRI scan of the spine. You say that the copayment should only be $30. The Plan denied your request. The Plan says the correct copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for a Medicare-covered MRI at a freestanding provider. You have been asked to pay a $100 copayment for an MRI scan of the spine. An MRI scan of the spine 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 MRI scan of the spine (72148) provided on July 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lumigan 0.01% Solution.

You asked the Plan to pre-approve the Lumigan. The Plan denied your request. The Plan says Lumigan is a
self-administered drug and does not fall under Part B coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Lumigan 0.01% Solution.

Benefits for the Lumigan may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the lumbar spine; without contrast material (72148) provided on May 12, 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 magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and an angiogram at a freestanding provider.
You have been asked to pay a $75 copayment for the Medicare-covered MRI rendered at a freestanding provider. 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 magnetic resonance imaging (MRI) of the lumbar spine; without contrast material (72148) provided on May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided January 8, 2021.

You asked the Plan to waive the copayment for the non-emergency ambulance transport. You say that the hospital ordered the medically necessary transport. The Plan denied your request. The Plan says the copayment was applied correctly. The Plan also says that they have reviewed call logs to verify that they did not provide incorrect information about the ambulance copayment.

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 $225 copayment for covered one-way ground ambulance services. 

You have been asked to pay a $225 copayment for the non-emergency ambulance transport. This ambulance transport falls within the Ambulance services 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 ambulance service, basic life support, non-emergency transport (A0428) and ground mileage, per statute mile (A0425) provided January 8, 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 you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation supports a need for physical and/or occupational therapy, there is no documented need for an
intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to
fully participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4341 x4) provided on April 13, 2021.
You asked the Plan to pay for the scalings and planings. You say that because of your health and possible infection issues, you were told that this cleaning at the time would be best for you. The Plan denied your request. The Plan says this procedure is not covered under your dental plan.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the four
periodontal scalings and root planings (D4341 x4) provided on April 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiac rehabilitation.

You asked the Plan to pre-approve cardiac rehabilitation. You say that you had cardiac rehabilitation previously approved. The Plan denied your request. The Plan says cardiac rehabilitation is not covered for your condition.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary cardiac rehab programs. The services must be provided in a doctor's office or an outpatient hospital setting. 

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 cardiac rehabilitation. Our reviewer says that you do not currently meet any of the CMS criteria for use of cardiac rehabilitation therapy. Our physician reviewer found that you have atypical chest discomfort with no history of prior myocardial infarction, angina pectoris, obstructive coronary artery disease, prior revascularization or significant valvular heart disease and no ischemia on recent stress testing. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cardiac rehabilitation have not been met. Therefore, we decided that the Plan does not have to pre-approve cardiac rehabilitation.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided April 22, 2021 to April 23, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met. Our physician reviewer found the enrollee presented to the hospital with shortness of breath and weakness for one week. She stated that she was not taking her diuretic Lasix medicine as prescribed, due to concerns about her urination amounts. She was treated with supplemental oxygen and intravenous (IV) Lasix. She was monitored overnight and described as "stable condition" and ready for discharge. The record does not show that, at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided April 22, 2021 to April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on May 12, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that this was a follow-up visit and you should not be charged a copayment. The Plan denied your request. The Plan says you have been asked to pay 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 $45 copayment for specialist physician services.
You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which states a copayment will be waived for a follow-up visit.
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 specialist office visit provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation
device for the enrollee.

You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that this service is not a covered Medicare benefit because acupuncture
for auricular stimulation does not meet the definition of reasonable and necessary.

The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electroacupuncture
devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to
pre-approve placement of an auricular peripheral nerve stimulation device for the enrollee.
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 you need more rehabilitation care, and you do not want to go to a nursing home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in a less intensive setting.

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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient therapy services provided on October 26,
2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the clinical
effectiveness for the services in the setting of chronic pain syndrome has not been demonstrated.
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 services provided. Our physician
reviewer found that the enrollee has chronic bilateral lower extremity peripheral neuropathy due to unknown
cause. She has tried Gabapentin and over the counter medications. In this case, the enrollee received electrical
cell stimulation, vasopneumatic therapy, and an injection of nutri-pharmaceuticals. The provided services are
not evidence based. Therefore, the procedures were 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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the outpatient therapy services provided on October 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 30, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that you were told that a panoramic x-ray was required in order to complete the necessary work. The Plan denied your request. The Plan says this service is not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 you do not require the services on an inpatient basis, only in a skilled nursing facility 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 skilled nursing facility (SNF) care.