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

 We decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.  You asked the Plan to pre-approve the Superion procedure. You say that this is a proven procedure which is medically necessary. The Plan denied your request. The Plan says there is not sufficient evidence to support medical necessity at this time.  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 Superion procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested device is experimental at this time. More research is needed to show safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Superion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of the Superion interspinous spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sacroiliac joint radiofrequency ablation (SI joint RFA) procedure provided on June 17, 2021.  You asked the Plan to pay for the SI joint RFA. You say that the SI joint RFA provided was medically necessary. The Plan denied your request. The Plan says the SI joint RFA provided was 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 pay for the SI joint RFA. Our reviewer says that the SI joint RFA provided was not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. He takes Oxycodone for pain and has tried over the counter medications including NSAIDs and Tylenol without sustained relief. His physical exam clearly documents Sacroiliitis. He underwent diagnostic SI joint blocks and then had RFA of the lateral sacral branches which produced 75% pain relief.   This was considered an experimental/investigational procedure because of the wide variation in efficacy reported in the literature.  Therefore, 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 the SI joint RFA have not been met. Therefore, we decided that the Plan does not have to pay for the sacroiliac joint radiofrequency ablation (SI joint RFA) procedure provided on June 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued rental of a continuous positive airway pressure (CPAP) device.  You asked the Plan to pre-approve the continued CPAP rental. You say that it is felt that this remains medically necessary. The Plan denied your request. The Plan says criteria for continued use have not been met.  The Plan must follow Medicare rules. Medicare rules say that continued coverage of CPAP beyond three months requires evidence that the enrollee has used the CPAP device for at least four hours on at least 70% of nights during a 30-day period.   The compliance reports show that the enrollee has not achieved use for at least 4 hours on 70% of nights during the trial period. As such, the criteria for continuation of coverage for the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued rental of a continuous positive airway pressure (CPAP) device.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost share for the arthrocentesis with fluoroscopy (20610) and the Part B drugs (J2001 and J3301) provided on August 2, 2021.  You asked the Plan to waive the cost share for the arthrocentesis with fluoroscopy and Part B drugs. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient surgical services with fluoroscopy and Part B drugs in an outpatient hospital facility setting on the date of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.  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 Outpatient surgery, a $35 copayment for Outpatient diagnostic tests, and a 20% coinsurance for Medicare Part B prescription drugs.   We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an arthrocentesis with fluoroscopic procedure and Part B drugs on August 2, 2021. You have been asked to pay a $225 copayment for the arthrocentesis procedure. The arthrocentesis procedure falls within the Outpatient surgery benefit category. You have been asked to pay a $35 copayment for the fluoroscopy. The fluoroscopy falls within the Outpatient diagnostic tests benefit category. You have been asked to pay a 20% coinsurance for the Part B drugs, totaling $3.93. The Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the arthrocentesis with fluoroscopy (20610) and the Part B drugs (J2001 and J3301) provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable ventilator.  You asked the Plan to pre-approve the ventilator. You say that a ventilator is necessary. The Plan denied your request. The Plan says the enrollee does not have a condition for which this can be covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 ventilator. Our reviewer says that the requested ventilator is not medically necessary. Our physician reviewer found the enrollee has a listed diagnosis of COPD, but without supporting pulmonary function tests.  The patient has suspected sleep apnea and is on chronic narcotics for pain. He was recently hospitalized for a change in mental status attributed to narcotics and sleep apnea. The patient improved markedly with overnight use of bilevel positive airway pressure (BiPAP). Testing showed on mild carbon dioxide retention. Medicare does not cover a ventilator for the enrollee's conditions.  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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion or replacement of the Optimizer Smart permanent CCM system (CPT code 0408T), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee suffers with dyspnea on exertion, shortness of breath and orthopnea. You state the enrollee has tried medication therapy of diuretic and beta blocker, that has not worked. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational because it is not identified as widely used and generally accepted as reported in nationally recognized peer-reviewed medical literature published in the English language.

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 an exhaustive review of the current medical literature pertaining to the CCM system confirms multiple observational studies suggesting clinical benefit from CCM. Several randomized clinical trials of CCM versus control have also been reported, along with meta-analysis pooling the data from multiple studies, with CCM providing meaningful improvement in quality-of-life scores and objective functional capacity. While the clinical studies led to Food and Drug Administration (FDA) approval in 2019, CCM remains the subject of multiple studies examining long-term efficacy, as well as randomized, controlled, double-blinded trials to quantify clinical efficacy. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. At the current time, our physician reviewer would not consider the CCM system to be medically necessary in this enrollee. 

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 insertion or replacement of the Optimizer Smart permanent CCM system (CPT code 0408T), for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Denosumab injection provided on July 1, 2021.  You asked the Plan to waive the coinsurance for the Denosumab injection. You say that you have never had to pay a copayment for any service while on this insurance plan. 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 20% coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs.    You have been asked to pay $251.66 which is 20% of the allowed amount for the Denosumab injection. The allowed amount is $1,258.32. ($1,258.32 x 20% = $251.66). The Denosumab injection 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 the Denosumab injection provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cervical injections.  

You asked the Plan to pre-approve the requested services. You say that you do not want surgery. The Plan denied your request. The Plan says a clear plan with documentation of precise levels is not able to be determined.  

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 requested services. Our physician reviewer found that you have chronic axial neck pain. You previously had cervical radiofrequency ablation with excellent results. This request is for diagnostic medial branch blocks (MBBs). There is no need to repeat diagnostic MBBs when there has been successful radiofrequency ablation. Therefore, the request for diagnostic MBBs 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the purchased portable Inogen G5 Oxygen Concentrator provided on July 9, 2021.  You asked the Plan to pay for the purchased Inogen oxygen system. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the denial of payment for these items is correct because purchased oxygen equipment is not covered under Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage and purchased oxygen equipment is statutorily non-covered.  We looked at the file and Medicare rules. Purchased oxygen equipment is not covered. Therefore, we decided that the Plan does not have to pay for the purchased portable Inogen G5 Oxygen Concentrator provided on July 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the x-ray of the ankle you received in a specialist's office on August 4, 2021.  You asked the Plan to waive the copayment for the x-ray. You say that you do not feel your copayment is accurate. The Plan denied your request. The Plan says you were charged this copayment correctly.  The Plan says that because the allowed amount for this service ($34.80) is less than your copayment obligation, you are responsible for the full allowed 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 $100 copayment for diagnostic procedures and tests.    You have been asked to pay a $100 copayment for the x-ray. The x-ray falls within the diagnostic procedures and tests 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 x-ray of the ankle you received in a specialist's office on August 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ophthalmic diagnostic testing provided on June 25, 2021.  You asked the Plan to waive the copayment for the ophthalmic diagnostic testing. You say that you paid your $45 specialist copayment, and you should not have an additional 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 $50 copayment for all other Medicare-covered outpatient diagnostic tests.   You have been asked to pay a $50 copayment for the ophthalmic diagnostic testing. The ophthalmic diagnostic testing falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the ophthalmic diagnostic testing is considered a separate service.  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 ophthalmic diagnostic testing provided on June 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on August 24, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that the service was medically necessary. You say most in-network providers cannot perform complex detailed drug testing services. The Plan denied your request. The Plan says no prior authorization was obtained.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the drug testing provided on August 24, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine foot care services you received on May 13, 2021.  

You asked the Plan to pay for the routine foot care services. You say that you get your toenails trimmed every three months and it has always been covered. The Plan denied your request. The Plan says routine foot care services are not covered unless you have diabetic foot disease.  

The Plan must follow Medicare rules. The rules say that routine foot care is generally excluded from coverage except for patients with diabetic foot disease. The services at issue in this appeal were routine foot care services.  There is no evidence that you have diabetic foot disease that would qualify you for coverage of routine foot care. Therefore, we decided that the Plan does not have to pay for the routine foot care services you received on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical trays (A4550) provided on March 15, 2021.  

You asked the Plan to pay for code A4550. 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 as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We looked at the file and Medicare rules. Code A4550 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the surgical trays (A4550) provided on March 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond December 27, 2021.  

You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that it is felt that the enrollee requires additional time in the inpatient facility. The Plan denied your request. The Plan says the enrollee is no longer receiving active treatment and can be managed at a lower 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 the continued inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically necessary beyond the date in question. Our physician reviewer found the enrollee was admitted on December 23, 2021 with schizophrenia. 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, auditory or visual hallucinations and without aggressive behaviors while not showing any acute threats of safety. The patient was cooperative and compliant with medication. 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 as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. The health plan's denial of continued inpatient psychiatric services appears appropriate. This enrollee did not require inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date 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.  

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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care beyond December 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure with code 62370-LT provided on December 15, 2020.

You asked the Plan to pay for the surgical procedure with code 62370-LT provided on December 15, 2020.
You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria
were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial stating the records show the services were provided on the left side and billed for the left side. The Plan requested a reopen and provided additional information. The Plan says that denied because the provider has billed with an inappropriate modifier for payment. The Plan states the
provider needed to bill the anatomic specific modifiers LT (Left side), RT (Right side), and 50 (Bilateral
procedure) to designate the area or part of the body on which the procedure is performed as well as the
appropriate diagnosis codes, both of which were omitted.

The Plan is correct in this case. The Plan must follow Medicare rules. The rules state that providers must bill
services with the appropriate anatomical modifiers and diagnosis codes. In this case, the claim billed lacks the
appropriate information required to pay for this service. Medicare billing criteria are not met. Therefore, we
decided that the Plan does not have to pay this claim as billed.