Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
You asked the Plan to pre-approve radiofrequency ablation to the SI joint. You say that this procedure is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says radiofrequency ablation to the SI join in the setting of SI joint dysfunction have not been demonstrated in the peer-reviewed literature.
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 radiofrequency ablation to the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this service is considered an experimental/investigational procedure because of the wide variation in efficacy described 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 radiofrequency ablation to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation to the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve ophthalmology services to be provided by an OON provider. You say that 
you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested 
services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network 
ophthalmology providers available to you that can provide the services you are requesting. 
 
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 
ophthalmology services to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral x-ray and fluoride varnish application provided on May 24, 2021.

You asked the Plan to pay for the intraoral x-ray and fluoride varnish application. You say that you called before the appointment and were told the provider was in-network. The Plan denied your request. The Plan says the claim reprocessed as a one-time exception to pay for the comprehensive oral evaluation, bitewing x-ray and prophylaxis according to your in-network benefits. The Plan also says that the intraoral x-ray and fluoride varnish application remain denied as non-covered benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral x-ray and fluoride varnish application provided on May 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.

You asked the Plan to pre-approve a Vertiflex Superion interspinous device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion interspinous device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex 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 a Vertiflex Superion interspinous device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion interspinous device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosentyx. 
 
You asked the Plan to pre-approve Cosentyx. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
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 Cosentyx.  
 
Benefits for Cosentyx may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on August 21, 2020. 
 
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 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. Review of the file shows the claim was billed with an inappropriate 
place of service 11. According to claims history, the specimen was obtained in a Skilled Nursing Facility POS 
31. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 21, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Superion Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for drug testing provided on May 13, 2021. 
 
You asked the Plan to pay for drug test. You say that you are appealing with records to prove the necessity of 
this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, 
because the records do not support that 22 or more drug classes were tested. 
 
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 G0483 is drug test(s), definitive; qualitative or quantitative, all sources, includes specimen validity 
testing, per day; 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the record clearly shows that 
more that 22 or more drug classes were included in this testing. Based on this information, we decided that 
Medicare rules for coverage of drug test have been met. Therefore, we decided that the Plan has to pay for drug 
testing provided on May 13, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99380) provided March 25, 2021. 
 
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 code 99380 is not supported in the medical record. Specifically, per the CMS Physician 
Relative Value File, the code billed has a status of "B". Payment is bundled with payment for another service. 
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 (99380) provided March 
25, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for the psychotherapy service (90832) provided on June 7, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the service was rendered by an out of network provider, without prior authorization.

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. 

Your facility is a contract provider with the plan that rendered the service in this case to the enrollee. The file does not show that the plan provided notice that this service would not be covered. Under Medicare rules, this means this service is considered approved by the plan. Therefore, we decided that the Plan has to pay for the psychotherapy service (90832) provided on June 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator.
You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation fails to indicate a non-union fracture.
The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days. 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 stimulator. Our reviewer says that the requested stimulator is not medically reasonable or necessary. Our physician reviewer found not enough time has passed since the initial fracture. At least nine months have to pass. The criteria has 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 the stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic bone growth stimulator.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the services can safely be received in a different setting.

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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97014) provided April 29, 2021 through 
June 28, 2021. 
 
You asked the Plan to pay for the therapy 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 code 97014 is not supported in the medical record. Specifically, per the National Physician 
Fee Schedule, CPT Code 97014 has a status of "I" and is invalid for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, 
we decided that the Plan does not have to pay for therapy services (97014) provided April 29, 2021 through 
June 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81291, 81407, 81408, 81479, and 
81439) provided on November 19, 2020. 
 
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 services are not covered. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services (81291, 81407, 81408, 81479, and 81439) provided on November 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF care provided from June 18, 2021, to July 2, 2021.
You asked the Plan to waive the copayment for the SNF care. You say that your stay was supposed to be for rehabilitation. You say you were never informed there would be a 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 $0 copayment for days 1 through 20 and a $184 copayment per day for days 21 through 100. You have been asked to pay a $920 copayment for the SNF care. The SNF care falls within the "Skilled nursing facility (SNF) care" benefit category. The record shows you were charged for 5 SNF days which is less than the standard copayment amount for these dates of 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 SNF care provided from June 18, 2021, to July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 31 to June 9, 2021.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the hospital's care caused a stroke, necessitating inpatient hospital care. You feel you should not be charged. The Plan denied your request. The Plan says the correct copayment was applied.
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 $295 copayment for each admission for a medically necessary inpatient stay. You have been asked to pay a $295 copayment for inpatient hospital care. 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 inpatient hospital care provided from May 31 to June 9, 2021.
Maximus Federal Services read your appeal and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869). 
 
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested procedure is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met 
because the requested procedure is experimental/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 a Vertiflex procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the requested procedure is considered experimental/investigational because it has 
not been shown to be superior to the standard treatment of surgical decompressio n. It is not included on 
standard treatment algorithms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of a Vertiflex procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Vertiflex procedure (22869).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on June 16, 2020.
You asked the Plan to pay for the emergency department visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with a primary/first-listed diagnosis code os T38.0X5A (adverse effect of glucocorticoids and synthetic analogues, initial encounter). Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, it is required that the underlying condition be sequenced first followed by the manifestation. That means the primary/first-listed diagnosis code is incorrect for this code. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on June 16, 2020.