Persius/hicric huggingface dataset:
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for the computed tomography (CT) scan provided on September 7, 2021.  You asked the Plan to pay for the services provided. You say that the test was recommended by your primary care physician. The Plan denied your request. The Plan says that the test is not a covered service.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  The file shows that a CT scan of the heart with coronary calcium scoring was provided. You were referred for the services by a contract provider. The file does not show that the Plan provided notice that the services provided would not be covered. Under Medicare rules, this means the services provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scan provided on September 7, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve radiofrequency ablation (CPT code(s): 64635-50, and 64636-50), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says that your request is not medically necessary because your records do not show the enrollee has achieved any success with the prior injections.  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 services. Our physician reviewer found the enrollee obtained greater than six (6) months of pain relief and meets the LCD criteria. The request is medically reasonable and 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 have been met. Therefore, we decided that the Plan has to pre-approve radiofrequency ablation (CPT code(s): 64635-50, and 64636-50), for the enrollee.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22899), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the service is considered experimental and investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22899), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for colonoscopy services (45380) provided on June 15, 2021, by a provider who has opted-out of Medicare.

You asked the Plan to pay for colonoscopy services. You say that you were not aware that this service would not be covered. The Plan denied your request. The Plan says except for emergency or urgent care services, payment will not be made to a provider who has opted-out of Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for colonoscopy services (45380) provided on June 15, 2021, by a provider who has opted-out of Medicare.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve left knee orthosis (L1846).  You asked the Plan to pre-approve the orthosis. You say that the enrollee has severe arthritis and could be a huge fall risk and could be hospitalized if he falls. The Plan denied your request. The Plan says the request for the left L1846 knee orthosis 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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was being treated for unilateral primary osteoarthritis right knee; and unilateral primary osteoarthritis, left knee. He presented with right knee pain status post total knee arthroplasty on 2/11/21, with noted contracture. The 9/16/21 notes states left knee pain. However, detailed documentation is not evident regarding any noted left knee recent injury or surgical procedure. Detailed documentation is not evident regarding any left knee instability or joint laxity. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  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 orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve left knee orthosis (L1846).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22899), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22899), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the enrollee has a pain pump they use and is in pain. You state that this causes the enrollee not to do daily activities. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use 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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve cochlear device implantation for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show bilateral sensorineural hearing loss.  The Plan must follow Medicare rules. Medicare rules say that for coverage of cochlear device implantation, there must be a diagnosis of bilateral moderate-to-profound sensorineural hearing impairment.  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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is not a diagnosis of bilateral moderate-to-profound sensorineural hearing loss (SNHL). On an audiogram on 8/12/1, the left ear did demonstrate moderate-to-profound SNHL, with a pure tone average of 92 dB; however, the right ear had normal hearing down sloping to mild SNHL (pure tone average 10 dB). Therefore, there is only a diagnosis of unilateral, not bilateral, moderate-to-profound SNHL.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cochlear device implantation for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services (90832) provided on July 7, 2021, to August 11, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy services. You say that the services provided were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 had network providers available who could have provided the items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90832) provided on July 7, 2021, to August 11, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on August 16, 2021.  You asked the Plan to waive the copayment for the CT scan of the abdomen and pelvis. You say that the services should be covered as they are too expensive. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $250 copayment for Outpatient diagnostic tests and therapeutic services and supplies.   You have been asked to pay a $250 copayment for a CT scan of the abdomen and pelvis. CT scans fall 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 a CT scan of the abdomen and pelvis (74177) provided on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.

You asked the Plan to pre-approve the service. You say that the condition has greatly reduced the quality and functionality of the enrollee's life. You state the enrollee has failed conservative approaches to treatment. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as it has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found interspinous spacer devices remain 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 5, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that that the doctor's office arranged the transportation for you, so since you did not arrange the transportation, you did not know it was not covered. The Plan denied your request. The Plan says ambulance services are not covered for transport to physician office visits.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ambulance service, basic life support, non-emergency transport. Our reviewer says that ambulance transport does not meet the Medicare coverage criteria. Our physician reviewer found the record indicates that you were transported to a physician office visit. The records provided are insufficient to determine your transportation needs. The record does not indicate that your clinical condition is such that other methods of transport are contraindicated. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services (99213, 17000, 17003) provided on March 12, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 had network providers available who could have provided the items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for the medical services (99213, 17000, 17003) provided on March 12, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve the concentrator. You say that this is medically necessary to be more mobile. The Plan denied your request. The Plan says the plan does not cover duplicate or redundant durable medical equipment such as an oxygen device when the second item performs the same function as the one currently provided to the enrollee.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  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 concentrator. Our reviewer says that the requested item is not medically reasonable or necessary. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD) and interstitial lung disease, and was hospitalized in 10/21. You were discharged on 4 L/min O2, but no indication of whether an O2 conserving device was being used. The records do not include oxygenation measurements during activity. The records do not document that the saturation can be maintained at least 91% during activity, using a conserving device with flow 1-4 L/min.  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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided on August 31, 2020, through September 10, 2020 and billed with Diagnosis Related Group (DRG) 193.  You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support diagnosis code G92.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code G92. 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 inpatient hospital services. Our reviewer says that the review has determined that the documentation did not support DRG 193 with a secondary diagnosis of toxic encephalopathy. Our physician reviewer found the documentation supported an admission for pneumonia. The documentation was unclear regarding a diagnosis of toxic encephalopathy. The member presented with complaints of weakness and altered mental status. There was no provider documentation in chart relating the diagnosis of encephalopathy to a cause.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on August 31, 2020, through September 10, 2020 and billed with Diagnosis Related Group (DRG) 193.