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

We decided that the Plan does not have to pre-approve spinal surgery.
You asked the Plan to pre-approve spinal surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 spinal surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interspinous 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 spinal surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal surgery.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Part B prescription drug provided on February 10, 2021.
You asked the Plan to waive the coinsurance for a Part B prescription drug. You say that you were not made aware of the coinsurance beforehand and that the cost is too much. The Plan denied your request. The Plan says the coinsurance applied was correct.
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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. The allowed amount of this claim is $1,212, resulting in a coinsurance amount of $242.40.
You have been asked to pay 20% coinsurance for a Part B prescription drug. A Part B prescription drug falls within the Medicare Part B Prescription Drugs 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 coinsurance for a Part B prescription drug provided on February 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation (A0425, A0428) provided May 6, 2021.
You asked the Plan to pay for the ambulance transportation. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says these services would be included in the enrollee's inpatient hospital costs.
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services, including transportation services, furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. The record shows that the enrollee was an inpatient at the time the service at issue is provided. That means that this service must be furnished directly by the hospital or billed through the hospital under arrangements and is not separately payable from the inpatient stay. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation (A0425, A0428) provided May 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from May 17, 2021, through June 15, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the continuation of SNF services is not medically necessary.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the documentation does not support the need for the continued stay in a SNF with daily skilled therapies in an inpatient setting beyond beyond May 15, 2021. Our reviewer says that the enrollee's care needs could be safely provided at an alternate and lower intensity 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the SNF services provided from May 17, 2021, through June 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar laminectomy.

You asked the Plan to pre-approve a lumbar laminectomy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 lumbar laminectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria is not met. There is no documentation of a recent trial and failure of an adequate trial of physical therapy 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 a lumbar laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar laminectomy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of EEG (95957), complete needle electromyography (95886), and nerve conduction study (95907).

You asked the Plan to pay for the billed codes. You say that the codes are correct and supported. The Plan denied your request. The Plan says the codes are not supported in the medical records.

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 95957 is a digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). A 95886 is a complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure. The 95907 is a nerve conduction studies; for 1-2 studies.

We asked our coder 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 billed codes. Our reviewer says that the service is not medically necessary.

Our reviewer found the technical report available in the case file does not include documentation of a digital analysis of electroencephalogram, and consequently the code 95957cannot be verified. The CPT code 95886-26 x2 is not supported in the available documentation in the case file. Procedure code 95907-26 is not supported by the medical records submitted. The technical report does not include documentation of nerve conduction studies; for 1-2 studies. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the billed codes have not been met. Therefore, we decided that the Plan does not have to pay for digital analysis of EEG (95957), complete needle electromyography (95886), and nerve conduction study (95907).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient psychotherapy services provided on May 21, 2021.
You asked the Plan to pay for the outpatient psychotherapy services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered
The Plan must follow Medicare rules. Medicare rules say that clinical psychology services must be provided by a clinical psychologist with a doctoral degree in psychology who is licensed and certified by the state. We looked at the file and Medicare rules. The file shows that the provider has an EdD (doctor of education) degree and not a doctorate in psychology. 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 outpatient psychotherapy services provided on May 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve 10 additional physical therapy visits. You say that the enrollee is moderate
in balance and strength deficits, moderate risk of falls and difficulty with activities of daily living. The Plan
denied your request. The Plan says additional visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 10 additional physical therapy visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent
deterioration of the enrollee's condition. Our physician reviewer found that the enrollee has had prior therapy
and has been instructed in a home exercise program. Our reviewer says that the unique skills of a professional
therapist are not required to safely and effectively provide ongoing treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 10 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 10 additional physical therapy visits
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional occupational therapy visits.
You asked the Plan to pre-approve these services. You say that additional occupational therapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of additional occupational therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that additional occupational therapy is not medically necessary. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and is at a supervision level for activities of daily living. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively be performed only by a therapist, or by or under the supervision of a therapist. The patient will continue to require cues and supervision at her long term care facility due to cognitive deficits. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional occupational therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dentalalveolar structures (41899 x56), reconstruction of mandible or maxilla, endosteal implant; partial (21248 x2), unlisted maxillofacial prosthetic procedure (21089 x7), augmentation mandibular body or angle; was bone graft (21127 x2), and formation; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet (15574 x2).

You asked the Plan to pre-approve dentalalveolar structures, reconstruction of mandible or maxilla, endosteal implant; partial, unlisted maxillofacial prosthetic procedure, augmentation mandibular body or angle; was bone graft, and formation; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet. You say that the services are necessary. The Plan denied your request. The Plan says the dental services requested are not covered prior to a kidney transplant.

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 pre-approve dentalalveolar structures (41899 x56), reconstruction of mandible or maxilla, endosteal implant; partial (21248 x2), unlisted maxillofacial prosthetic procedure (21089 x7), augmentation mandibular body or angle; was bone graft (21127 x2), and formation; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, or feet (15574 x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from January 14, 2021,
through January 18, 2021.

You asked the Plan to pay for the inpatient hospital services. You say that this was billed correctly and should
be paid. The Plan denied your request. The Plan says the claim has an inappropriate entry for the POA
indicator.

The Plan must follow Medicare rules. Medicare rules say that diagnosis codes that are exempt from POA
reporting should be identified with a blank POA indicator field or with an entry of "1".

In this case, diagnosis code Z86.16 (personal history of COVID-19) was reported with POA indicator of "Y".
This code is exempt from POA reporting as should have been listed with an indicator of 1.

As this diagnosis is not correctly reported, the claim denial is appropriate. Therefore, we decided that the Plan
does not have to pay for the inpatient hospital care provided from January 14, 2021, through January 18, 2021.
Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to reduce the cost sharing for the medical eye exams. We decided that the Plan does not have to waive the cost sharing for the visual field testing and the computerized ophthalmic imaging services.
You asked the Plan to waive the cost sharing for the ophthalmology services. You say that you believe you are being charged incorrectly and that you are being assessed a facility fee. The Plan says that you were charged this cost sharing correctly.
We decided that the Plan has to reduce the cost sharing for the three medical eye exams.
According to the case file, you received three medical eye exams (codes 92014 and 92012). It appears from the case file that the Plan incorrectly processed the claims for these medical eye exams as though they were diagnostic testing services. Medical eye exams are not diagnostic testing services. These billed codes clearly represent medical eye exams. According to your Evidence of Coverage (EOC), medical eye exams only have a $50 copayment. The Plan has charged you cost sharing of $70.99 for the two eye exams billed with code 92014, and $53.24 for the eye exam billed with code 92012. Because these cost sharing amounts exceed the listed cost sharing for medical eye exams in your EOC, we find that the Plan must reduce your cost sharing for these services. The total cost sharing that the Plan has charged you for these three medical eye exams is $195.22 ($70.99 + $70.99 + $53.24 = $195.22). However, the maximum that the Plan should have charged you is $150 ($50 x 3 = $150). Therefore, we find that the Plan must reduce the cost sharing for the medical eye exams by $45.22. We also decided that the Plan does not have to waive the cost sharing for the visual field testing and the computerized ophthalmic imaging services.
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 20% coinsurance for diagnostic tests. Both of these services are diagnostic testing services, and this coinsurance applies regardless of the location where the services are rendered. Therefore, we decided that the Plan does not have to waive the cost sharing for the visual field testing and the computerized ophthalmic imaging services.
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 comprehensive oral exam (D0150) provided July 15,
2021.
You asked the Plan to pay for the dental services. You say that the dental code had already been used by you
went to another doctor and they performed the same service. The Plan denied your request. The Plan says this
service exceeds the benefit maximum limitation.
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. This service is allowed one
procedure every 3 plan years. The records show this service was provided May 1, 2019 and was paid May 10,
2019.
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
comprehensive oral exam (D0150) provided July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring provided during a surgery on March 26, 2021, billed with codes 95886, 95908, 95937, and 95955.
You asked the Plan to pay for the services as billed. You say that this was billed correctly. The Plan denied your request. The Plan says the codes at issue 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 95886 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). 95908 is defined as Nerve conduction studies; 3-4 studies. Code 95937 is defined as Neuromuscular junction testing (repetitive stimulation, paired stimuli), each
nerve, any 1 method. Code 95955 is defined as Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). We asked our 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 as billed. Our reviewer says that the report does not support the use of the billed codes. Our reviewer found the enrollee is a 65-year-old woman who underwent L1-2 decompression fusion surgery. Neurophysiologic monitoring was ordered. The requested procedure codes are not substantiated by the clinical documentation in the technical report submitted for review. The necessary information was not documented in the operative report narrative. We looked at this review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring provided during a surgery on March 26, 2021, billed with codes 95886, 95908, 95937, and 95955.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special anesthesia services rendered on April 16, 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 code 99100 is not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is
always bundled into payment for other services not specified.

We looked at the file and Medicare rules. The file shows that billed procedure code 99100 (special anesthesia
services) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan
does not have to pay for the special anesthesia services rendered on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Rezum procedure (53854).
You asked the Plan to pre-approve a Rezum procedure. You say that alternative treaments are a risk for you. The Plan denied your request. The Plan says the clinical guidelines for this procedure have not been met.
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 Rezum procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the American Urological Association (AUA) considers transurethral destruction of prostate tissue; by radiofrequency generated water thermotherapy, also known as the Rezum procedure, to be a viable treatment of benign prostatic hyperplasia (BPH). However, the Rezum procedure is indicated for men 50 years and older with a prostate volume between 30 cubic centimeters and 80 cubic centimeters. The records state that the prostate size in this case is 104 cubic centimeters, which is larger than the approved size. 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 Rezum procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Rezum procedure (53854).