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

We decided that the Plan does not have to pre-approve the X-Spine Axle Interspinous Fusion System and bone marrow aspirate procedure.
You asked the Plan to pre-approve the X-Spine Axle Interspinous Fusion System and bone marrow aspirate procedure. You say that this is medically necessary. The Plan denied your request. The Plan says these are both experimental/investigational services.
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 X-Spine Axle Interspinous Fusion System and bone marrow aspirate procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found both of the requested procedures 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 X-Spine Axle Interspinous Fusion System and bone marrow aspirate procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the X-Spine Axle Interspinous Fusion System and bone marrow aspirate procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. The Plan denied your request. The Plan says the records do not show that you require skilled nursing services or skilled rehabilitation services on a daily basis.

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 the specialized skill, knowledge, and judgment of a skilled professional nurse are not required, and daily skilled therapy services are not required. 

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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for physician's service provided on
June 1, 2021.
You asked the Plan to waive the deductible for physician's services. You say that this visit was for an eye exam and is covered once every two years. The Plan denied your request. The Plan says per the Plan benefits the total cost share applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is $198 deductible which applies to Vision Care Medicare-covered eye exams to evaluate for eye disease (in and out-of-network). The item or service you asked the Plan to waive the deductible for falls within the Vision Care Medicare-covered eye exams to evaluate for eye disease (in and out-of-network) benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $198 deductible which applies to Vision Care Medicare-covered eye exams to evaluate for eye disease (in and out-of-network). This cost sharing is a contractual obligation that had not been met at the time physician's services was received on June 1, 2021.
Therefore, we decided that the Plan does not have to waive the deductible for physician's service provided on June 1, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea (J0178).  You asked the Plan to pre-approve Eylea. You say that the requested drug is medically necessary. You also say that you have not received your order of Avastin. The Plan denied your request. The Plan says the enrollee has not tried and failed the required drug, bevacizumab.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Eylea. Our reviewer says that the step therapy criteria have not been met. Our physician reviewer found the provided documentation does not indicate that the enrollee has tried and failed the required drug, bevacizumab. The reviewer found that there is no documentation indicating that the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy criteria have not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Specifically, the file does not show that the enrollee has tried and failed the required drug. Therefore, we decided that the Plan does not have to pre-approve Eylea (J0178).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care (99233) provided on September 20, 2021.  You asked the Plan to pay for code 99233. 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. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99233 is a column II code to column I code 38222. This claim has not been billed with an appropriate modifier to bypass the edit. 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 subsequent hospital care (99233) provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (34713-LT and 34713-RT) provided on August 26, 2021.  You asked the Plan to pay for code 34713. 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 claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 34713 have not been met. Therefore, we decided that the Plan does not have to pay for the Percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (34713-LT and 34713-RT) provided on August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ultrasound guidance (76937) provided on March 19,
2021.
You asked the Plan to pay for code 76937. 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.
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76937
is a column II code to column I code 93970. This claim has not been billed with an appropriate modifier to
bypass the edit. 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 Ultrasound guidance (76937) provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the Orencia infusion you received on July 29, 2021.  

You asked the Plan to waive the coinsurance for the Orencia infusion. You say that you cannot afford this medication. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  

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 drugs.   

You have been asked to pay 20% coinsurance for the Orencia infusion. The Orencia infusion falls within the Medicare Part B 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 Orencia infusion you received on July 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation mileage.

You asked the Plan to provide additional mileage. You say that you will need to see this provider a few times in the future, and this transportation is necessary for you to get to your appointments. The Plan denied your request. The Plan says the requested location is greater than 50 miles of driving distance away. Routine transportation is limited to 50 miles per trip.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage.

For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when trips are provided to or from Plan-approved locations and do not exceed 50 miles of driving distance. 

We looked at your request, the records in the case file, and the rules. The requested location is greater than 50 miles away from your home. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to provide additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone density scans (77080 and 77081) provided on November 13, 2020.
You asked the Plan to pay for the bone density scans. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 77080 and 77081 and CPT code 77080 has exceeded the MUE frequency.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. Medicare rules also say that providers must report services correctly. In this case, the MUE for CPT code 77080 is 1. The MAI value for this code is 2. You billed 2 units of this code on the same date of service, exceeding the MUE. Additionally, an NCCI edit exists between CPT codes 77080 and 77081. CPT code 77081 has not been billed with a modifier to bypass this edit. Based on this information, we decided that Medicare rules for coverage of the bone density scans have not been met. Therefore, we decided that the Plan does not have to pay for the bone density scans (77080 and 77081) provided on November 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroplasty (27130) provided on August 16, 2021.

You asked the Plan to pay for the arthroplasty. 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 the service billed.

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 27130 is arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. 

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 arthroplasty. Our reviewer says that CPT code 27130 does not meet criteria for billing or reimbursement consideration. Our reviewer found the provider is reporting modifier -22 for increased procedural services for robotic assisted arthroplasty hip.

Modifier 22 may only be used when substantial additional work is performed that is unrelated to robotic assistance. 

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 arthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for the arthroplasty (27130) provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit with an oncologist you had on July
21, 2021.
You asked the Plan to waive the copayment for the oncology visit. You say that the doctor only visited you
briefly when you were in the hospital. You said that because there was no formal appointment conducted,
there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for visits or consultations with a specialist in an outpatient location.
You have been asked to pay a $45 copayment for the oncology visit. This copayment applies regardless of how
long the visit lasts or whether it was a scheduled visit. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the visit with an oncologist you had on July 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021.  

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the enrollee had another insurer as the primary insurance provider for this date of service.    

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the laboratory services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 24, 2021.
You asked the Plan to pay for physician's services. You say that The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on August 13, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic knee feature (L5845).

You asked the Plan to pre-approve a prosthetic knee feature. You say that this should be approved. The Plan denied your request. The Plan says this is included in the approved prosthesis.

The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. 

The requested knee feature is included in the previously approved knee flexibility feature and cannot be separately approved. Therefore, we decided that the Plan does not have to pre-approve a prosthetic knee feature (L5845).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on October 4, 2021.  You asked the Plan to pay for the pain management 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 for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. In this case, there were no medical records provided for review to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on October 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zip spinal fusion.

You asked the Plan to pre-approve Zip spinal fusion. You say that the requested zip interlaminar fusion device/aurora zip procedure is medically necessary. The Plan denied your request. The Plan says the requested zip interlaminar fusion device/aurora zip 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 Zip spinal fusion. Our reviewer says that the requested zip interlaminar fusion device/aurora zip procedure is not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. He has tried ice, heat, and home exercises. His Magnetic resonance imaging (MRI) shows multi-level degenerative disc disease, facet arthropathy at L5-S1 and spinal stenosis. The requested procedure is considered experimental/investigational. Therefore, the request is considered 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 Zip spinal fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve Zip spinal fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 00860 billed for date of service June 15, 2021.

You asked the Plan to pay for procedure code 00860. You say that the medical records support payment of this code. 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. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of procedure code 00860 is anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified for services performed.

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 procedure code 00860. Our reviewer says that the medical records do not support billing of this code. Our reviewer found the patient underwent a revision of ileostomy procedure. Procedure code 00860 includes the urinary tract, a revision of ileostomy does not include the urinary tract. An ileostomy is a procedure in which the lumen of the ileum, part of the small bowel, is brought through the abdominal wall via a surgically-created opening called a stoma. A simple revision would involve removing adhesions/scar tissue pressing on the end of the ostomy. There is a more appropriate code to report for the procedure documented, as this procedure is performed on anterior abdominal wall.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 00860 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 00860 billed for date of service June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin tablets for the enrollee.

You asked the Plan to pre-approve Oxycontin tablets. You say that Oxycontin tablets are medically necessary. The Plan denied your request. The Plan says Oxycontin tablets are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Oxycontin tablets for the enrollee.

Benefits for Oxycontin tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.