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

We decided that the Plan does not have to pre-approve Vertiflex superion device placement surgery for the enrollee.
You asked the Plan to pre-approve these services. You say that the insertion of a lumbar interspinous spacer would provide significant clinical and quality of life benefits for your patient. The Plan denied your request. The Plan says that experimental and investigational procedures are not covered by Medicare.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 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 Vertiflex superion device placement surgery for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency ambulance transportation services (A0429, A0425) provided on April 18, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you do not agree with these charges. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.
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 $325 copayment for each covered, one-way ambulance trip by ground or water.
You have been asked to pay a $325 copayment for the ambulance services. 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 emergency ambulance transportation services (A0429, A0425) provided on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750) and a vision supply (V2797) provided on April 22, 2021.
You asked the Plan to pay for eyeglass frames, progressive lenses, anti-reflective coating and a vision supply.. You say that you do not agree with your responsibility of the claim. The Plan denied your request. The Plan says you exhausted your benefit, and you are responsible for the remaining balance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract also says that you receive a $250 allowance for one pair of eyeglasses every 2 calendar years from participating network providers. We looked at the file and the Plan's rules. The records show you exhausted your $250 maximum allowed benefit on April 22, 2021. The records also show your total amount of the claim was $612. The provider removed a charge of $50 for a vision supply. You received the total allowed amount of $250, leaving a balance of $312, which is your responsibility ($612 - $50 - $250 = $312). Based on this information, we decided that the Plan's rules for coverage of eyeglass frames, progressive lenses, anti-reflective coating and a vision supply. have not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames (V2020), progressive lenses (V2781), anti-reflective coating (V2750) and a vision supply (V2797) provided on April 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee's records do not show that the enrollee has signs/and or symptoms of heart disease.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 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 CT scan. Our physician reviewer found the clinical value and effectiveness of Quantitative Calcium Scoring in the setting of an asymptomatic patient and testing reported in isolation has not been demonstrated in the peer-reviewed literature. The review has determined that the requested CT Scan 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium (CPT code 75571), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9752 and C9753).
You asked the Plan to pre-approve the intracept procedure. You say that given your history, physical examination, the debilitating nature of your pain, and radiological findings, the intracept procedure is medically necessary. The Plan denied your request. The Plan says the services are 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 intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure remains experimental. More research is needed to show safety and efficacy of the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 22899, C9752 and C9753).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (CPT code(s): E1007, E0955, E1028 and K0861), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee has been diagnosed with cerebral palsy. The Plan denied your request. The Plan says the medical need for the Group 3 power wheelchair has not been established and therefore, denied as not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 DME. Our physician reviewer found the power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (CPT code(s): E1007, E0955, E1028 and K0861), for the enrollee is not medically necessary. The medical records provided do not meet the requirements listed in the LCD for Medicare coverage. The enrollee has some mobility issues, but the documentation does not indicate they impair MRADLs in the home. The physician documentation notes the enrollee walks long distances at least one mile and is requesting the power mobility device for outside the home. The patient's mobility deficit currently does not require an assistive device in the home as the physician documentation indicates the enrollee has mobility limitations with long distances. The physician documentation does not reveal a detailed neuromuscular exam indicating why the enrollee would be unable to use a walker, cane, or manual wheelchair. The physician documentation does not reveal evidence of increased tone, contractures, or weakness that would prevent the use of these devices. The enrollee may have the cognition to operate a PMD, but the documentation does not support it is medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds and accessories (CPT code(s): E1007, E0955, E1028 and K0861), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and complete denture - mandibular (CPT code D5120).
You asked the Plan to pre-approve the dental services. You say that you have a letter from your doctor stating it is medically necessary in order for you to be able to eat. You state you have not been able to chew food and eat properly. The Plan denied your request. The Plan says you exhausted your benefit.
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. Review of the file shows that you had the services D5110 and D5120 rendered on May 23, 2018. The plan does not allow for these services more than once every five (5) years. Therefore, we decided that the Plan does not have to pre-approve complete denture - maxillary (CPT code D5110) and complete denture - mandibular (CPT code D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (20982, 99153) provided June 26, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. We find that CPT codes 20982, & 99153 are not supported in the medical record. Specifically, CPT code 36561 was previously billed and has a global surgery value of 10 days. CPT 20982 was billed within the global surgery period and was not billed with a required modifier. CPT 99153 has a professional component / technical component value of 3 and cannot be paid for the place of service on the claim. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.
Therefore, we decided that the Plan does not have to pay for physician services (20982, 99153) provided June 26, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the enrollee has no skilled nursing needs and does not need the skills of a therapist 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 services. Our physician reviewer found that the enrollee is currently unable to actively participate in therapy and is limited by his cognition. Physical therapy is needed to see if the enrollee's ability to follow commands improves. The records anticipate that he is near his new baseline and would require a lift for safe transfers. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing need.s The enrollee does not require skilled nursing or therapy services on a daily basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a folding wheeled walker (E0143) provided on April 30, 2021, by an online retailer not enrolled in the Medicare program.
You asked the Plan to pay for a folding wheeled walker. You say that no local supplier of durable medical equipment listed by the Plan would provide the item at issue. The Plan denied your request. The Plan says rules for payment have not been met because the supplier in this case is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a folding wheeled walker (E0143) provided on April 30, 2021, by an online retailer not enrolled in the Medicare program.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar (CPT code 63030), laminectomy, facetectomy, and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment; lumbar (CPT code 63047) and laminectomy, facetectomy, and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment; each additional segment (CPT code 63048), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not necessary based on the Plan's guidelines.
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 medical records do not show that the imaging study, magnetic resonance imaging (MRI), shows any evidence of severe spinal stenosis. Criteria for laminectomy surgery not 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 the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar (CPT code 63030), laminectomy, facetectomy, and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment; lumbar (CPT code 63047) and laminectomy, facetectomy, and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)), single vertebral segment; each additional segment (CPT code 63048), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, spinal canal and contents, lumbar; without
contrast material (CPT code 72148) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the MRI. You say that you have severe pain and claustrophobia or open
standard magnetic resonance imaging and cannot take medication for the regular one. The Plan denied your
request. The Plan says there are in-network provider(s) within a reasonable distance from your location that can
provide this service or item.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148) to be provided by an outof-
network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on May 10, 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 codes 14301 and 14302 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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). We find that procedure codes 14301 and 14302 are not supported in the medical record. Specifically, there is no documentation of adjacent tissue transfer of any area for 30.1 sq cm to 60.0 sq cm to support code 14301. Given that primary procedure code 14301 is not supported, add-on code 14302 is also not supported.
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 surgical services rendered on May 10, 2021.
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. You say that there is no way you can be taken care for at home because of the cerebral infraction with your type 2 diabetes. The Plan denied your request. The Plan says the stay 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. Although you have made slow progress with therapy, your functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehab services is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the request 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 pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not have documented skilled nursing needs nor documented skilled therapy needs. You are consistently ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care. 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.