Persius/hicric huggingface dataset:
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 the Intracept procedure. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is 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 the Intracept procedure. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the review indicates the member has had persistent and chronic lower back pain. The pain is intermittent and described as aching, burning, sharp, and 7/10 on pain scale. The enrollee's symptoms are aggravated by sitting and are relieved with pain medication. She denies any radiating pain down bilateral lower extremities. She also has muscle cramps in both legs. Methocarbamol has been helpful when needed. A lumbar Magnetic resonance imaging (MRI) from May 6, 2021 reported anterolisthesis at L3-4 and L5-S1 with facet arthropathy at multiple levels, most prominent at L5-S1. Sacral x-rays done in 2018 showed no pathology. The member completed
lumbar diagnostic radiofrequency ablation (RFA) on July 6, 2021 but only received minimal pain relief. The review indicates that the Intracept procedure targets the basivertebral nerve for the relief of chronic verterbrogenic low back pain. Medicare guidelines consider this type of system unproven and not medically necessary. Large well-designed studies in the peer review scientific literature comparing stand-alone use of Intracept device to established surgical decompression are needed. Published studies do not demonstrate any long-term health outcome advantage with the use of Intracept as an alternative to standard surgical treatment. The review has determined that the requested Intracept procedure is not medically reasonable and necessary for the enrollee 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 the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on May 26, 2021.
You asked the Plan to waive the copayment for vision care. You say that you did not want to have your eyes
dilated and only wanted a routine exam. 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 $0
copayment for glaucoma screenings and diabetic retinal exams and a $25 copayment for all other vision
services.
The medical records show that you received diagnostic vision services on May 26, 2021. Therefore, you are
responsible to pay the $25 copayment.
You have been asked to pay a $25 copayment for vision care. Vision care falls within the vision care 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 vision care provided on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit for the evaluation and management of an
established patient (99212) rendered by the OON provider on June 11, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the office visit for the evaluation and management of an established patient (99212)
rendered by the OON provider on June 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device is experimental. More research is needed to show it is safe and effective. 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869, 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically
necessary. The Plan denied your request. The Plan says the requested Vertiflex device is 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 a Vertiflex device. Our reviewer says
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee has
chronic low back pain from spinal stenosis with neurogenic claudication. He takes Lyrica, Baclofen, Tylenol
and Aleve. He has tried physical therapy and is doing a Home exercise program. On Magnetic resonance
imaging (MRI), he has a disc protrusion at L4-L5 along with facet arthropathy causing spinal stenosis and
neuroforminal stenosis. The request is for placement of an interspinous spacer. This device is not part of
evidence-based algorithms for the treatment of spinal stenosis. The request is deemed 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does
not have to pre-approve a Vertiflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 5, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care. 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 services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for the subsequent nursing facility care provided on August 5, 2020,
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 27,
2021.
You asked the Plan to pay for the dental service. You say that this procedure was done before you had a root
canal. You say that a week after you had been to see your dentist, you developed a tooth ache. You say that an
x-ray showed you had an abscess. You also say that you were sent to an endodontist for a root canal. The Plan
denied your request. The Plan says 1 limited oral evaluation is covered per plan year. 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.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The
record shows that the Plan paid for a limited oral evaluation that you received on May 26, 2021. Therefore, we
decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on December 18, 2019.
You asked the Plan to pay for physical therapy services. The Plan denied your request. The Plan says the new
documents submitted for this appeal consist of progress notes for various dates other than the billed date of
service. Duplicates of records previously reviewed were also submitted.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents
to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the
physical therapy have not been met. Therefore, we decided that the Plan does not have to pay for physical
therapy services provided on December 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for an inpatient hospital stay provided from April 19, 2021, to April 27, 2021.
You asked the Plan to reduce the copayment for an inpatient hospital stay. You say that you had to be readmitted due to an infection and would like the charges to be reduced. 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 $295 copayment for days 1-5 for inpatient hospital care. The record shows that you had an inpatient hospital stay from April 19, 2021, to April 27, 2021. Therefore, you are responsible to pay a $295 copayment for days 1-5 (April 19, 2021, to April 23, 2021). The total amount you
owe is: $295 (copayment) x 5 (inpatient days) = $1,475. You have been asked to pay the total copayment amount of $1,475 for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 reduce the copayment for an inpatient hospital stay provided from April 19, 2021, to April 27, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied
your request. The Plan says rules for SNF care have 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 that at the time of discharge from the skilled
nursing facility the member had stabilized medically. The member did not require any skilled nursing or rehab
services on a daily basis at an inpatient level of care. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or
activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient
basis, at a SNF level of care at the time of discharge from the hospital. The member did not have any parental
medication, complex wound care or nutrition given via a feeding tube. She was medically stable without any
acute exacerbations of chronic medical problems. Her physical function was at or near her new baseline and
she could have received further services at a lower level of care. Continued care at a skilled nursing facility at a
skilled level of care for inpatient skilled services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on June 3, 2021, by an OON
provider.
You asked the Plan to pay for the domiciliary 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 must 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 the domiciliary visit provided on June 3, 2021, by an OON
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Special Supplemental Benefits for The Chronically Ill.
You asked the Plan to pre-approve Special Supplemental Benefits for The Chronically Ill. You say that you
would like approval for the services. The Plan denied your request. The Plan says you do not qualify for the
special supplemental benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for
enrollees with an eligible chronic condition.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of Special Supplemental Benefits for the Chronically Ill have not been met. Specifically, we have
confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we
decided that the Plan does not have to pre-approve Special Supplemental Benefits for The Chronically Ill.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided from March 26, 2021, to March 27, 2021.
You asked the Plan to pay for the emergency room services. You say that the enrollee had to go to the hospital to be evaluated. You also say that the enrollee needed to be moved to a different facility. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
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 the emergency room services provided from March 26, 2021, to March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan has to pay for drug testing (G0483) provided on August 19, 2020.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says that the record does not show that at least 22 drug classes were tested.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that 23 drug classes were tested on this date of service. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on August 19, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2740) provided on October 28, 2020.
You asked the Plan to pay for the crown. You say that you had to pay $500.00 out of pocket for this crown, and
you would like to be reimbursed. The Plan denied your request. The Plan says this service is not covered by the
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 crown
(D2740) provided on October 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography of the head (70544)
provided on May 30, 2021.
You asked the Plan to pay for the magnetic resonance angiography of the head. You say that you would like
this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not
billed with an appropriate modifier as required by Medicare.
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 70544
has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate
line item. 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 magnetic resonance angiography of the head (70544) provided on
May 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) coded 70450 provided on July 17, 2021.
You asked the Plan to pay for the CT. 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 70450 for the CT has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 computed tomography (CT) coded 70450 provided on July 17, 2021.