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

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic back pain with spinal stenosis. The requested Superion spacer is considered experimental/investigational in nature. It is not supported by two learned Orthopedic societies. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says this 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 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 for low back pain treatment. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that you fall with a walker. The Plan denied your 
request. The Plan says coverage criteria have not been met. 
 
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 a power scooter. Our physician 
reviewer found that you have a past medical history of chronic back pain, degenerative disc disease and falls. 
There is inadequate detail in the documentation to certify that you have a personal mobility deficit that impairs 
participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in 
customary locations within the home. There is documentation that your mobility deficit cannot be helped by the 
use of a walker due to back pain and falls, but there is no documentation that your mobility deficit cannot be 
helped by the use of a manual wheelchair. There is no documentation that you can safely operate a power 
mobility device. Therefore, the requested power scooter is not medically necessary at this time.  
 
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 power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on March 29, 2019, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the medical services. You say that the enrollee provided you with Original 
Medicare insurance when the services were rendered. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the 
item/service at issue. It is the provider's responsibility to confirm insurance coverage prior to rendering 
services. 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 medical services provided on March 29, 2019, by an out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit (G0439) provided on June 25, 2021 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the annual wellness visit. You say that you would like reconsideration because 
this service was rendered by the primary care physician. The Plan denied your request. The Plan says this 
service was rendered out-of-network and was not urgent, emergent or approved in advance. 
 
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 annual wellness visit (G0439) provided on 
June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure codes 99100 and 99140) provided to the enrollee on May 8, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says no separate payment is made for these cases.
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 the denied codes is: CPT 99100: Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)
CPT 99140: Anesthesia complicated by emergency conditions (specify) (List separately in addition to code for primary anesthesia procedure) We find that CPT codes 99100 and 99140 are not supported in the medical record. Specifically, these codes have a status indicator of "B." This means that this code cannot be paid for separately and is always bundled into payment for other services not specified. 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 pay for anesthesia services (procedure codes 99100 and 99140) provided to the enrollee on May 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on March 
1, 2020, and March 2, 2020. 
 
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says a review of the records supports DRG 641 rather than DRG 640, which is not supported. 
 
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 DRG 640. The plan states that the correct DRG is 
640. 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 services. Our reviewer says that the 
services at issue in this case were not supported by the medical records. Our physician reviewer found the 
review indicates that the documentation supported an admission for hyponatremia. The documentation was 
inconsistent/unclear regarding a diagnosis of acute respiratory failure with hypoxia. Even though acute 
respiratory failure with hypoxia is documented on the history and physical, consultation and discharge 
summary, supporting medical record documentation was not found within the record. The review has 
determined that the records did not support DRG 640 as billed. The plan's alternative of DRG 641 is correct.  
 
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 inpatient hospital services provided to the enrollee on March 1, 2020, and March 2, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the ambulance service, basic life support, 
non-emergency transport (A0428) provided on June 3, 2021. 
 
You asked the Plan to waive the cost share for the ambulance service. You say that you were advised that the 
nearest hand surgeon was 2 hours away. You say that your husband was not allowed in with you. You say that 
you were advised if you did not take the ambulance to the hospital, that the emergency room visit would not be 
covered. You also say that you feel you should not be responsible for this bill. The Plan denied your request. 
The Plan says there is a $250 copayment for covered ambulance services. The Plan says that the claim was 
processed correctly. The Plan also says that since the allowed amount is less than the copayment, the lesser 
amount was assessed to member liability. 
 
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 $250 
copayment for ambulance services.  
 
You have been asked to pay $226.97 copayment for the transportation service. The ambulance service falls 
within the ambulance services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan as the allowed amount is less than the $250 copayment amount. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the cost share for the ambulance service, basic life support, non-emergency 
transport (A0428) provided on June 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
You asked the Plan to pre-approve the Superion interspinous spacer device. The Plan denied your request. The Plan says this 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 Superion interspinous spacer device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer remains 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 the Superion interspinous spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion interspinous spacer device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep brain stimulation for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no evidence of a covered condition for this request. 
 
The Plan must follow Medicare rules. Medicare rules say that deep brain stimulation is only covered for 
Parkinson's disease or essential tremor.  
 
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 the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there is only coverage for this request with a diagnosis of essential tremor and Parkinson's disease, when 
specific coverage criteria are met. In this case, the enrollee is noted to have dystonia with a presentation in a 
Parkinson's-like manner. The criteria state that this request is otherwise not covered for use in non-idiopathic 
Parkinson's disease or "Parkinson's Plus" syndromes. In this setting and context, the requested stimulation 
would not meet the coverage requirements. 
 
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 deep brain stimulation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lower partial denture adjustment (D5422) provided on September 7, 2021.
You asked the Plan to pay for the dental service. You say that your denture are causing you a lot of pain. You also say that you need to get adjustments done. The Plan denied your request. The Plan says 2 partial denture adjustments are covered per denture, per plan year. The Plan also says that the frequency limit has been exceeded.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have not been met. Specifically, the frequency limit has been exceeded. The record shows that the Plan paid for partial denture adjustments for your lower partial denture that you received on July 1, 2021, and July 22, 2021. Therefore, we decided that the Plan does not have to pay for the lower partial denture adjustment (D5422) provided on September 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the comprehensive oral evaluation
(D0150), complete series x-ray (D0210), and panoramic x-ray (D0330), provided on May 19, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you do not understand
why the plan did not pay what the dentist charged. You say that you have $2,000 for dental services. You say
that the plan knew that your dentist was out of network. You also say that the plan advised they would pay for
the services whether the dentist was in or out of network. The Plan denied your request. The Plan says that 1
panoramic or complete series x-ray is covered every 5 years. The Plan says that the frequency limit for this
service has been exceeded. The Plan also says that out of network providers may bill you for any amount
greater than what the Plan pays the provider.
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 and complete series x-ray is listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid the allowed amount for
the panoramic x-ray that you received on the date of service in this case. Additionally, out of network providers
may bill you for any amount greater than what the Plan pays. This is a contractual obligation you agreed to
when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an
additional amount for the comprehensive oral evaluation (D0150), complete series x-ray (D0210), and
panoramic x-ray (D0330), provided on May 19, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on March 19, 2021.
You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive any skilled services on the date of service in this case. The Plan also says when the enrollee enrolls in a Medicare-certified hospice program, their hospice services and Part A and Part B services related to their terminal condition are paid for by Original Medicare.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge day services provided on February 1, 2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was a patient in the hospital 
when services were rendered. The Plan denied your request. The Plan says the billed code cannot be verified.  

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 99239 is hospital discharge day management; more than 
30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, the records do 
not show that more than 30 minutes of discharge management was provided. Based on this information, we 
decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided 
that the Plan does not have to pay for the discharge day services provided on February 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says your mobility needs are for outside of the home.

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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the provided records report that the power mobility device is not for use in the home but is intended for use in the community only. There is conflicting documentation with regards to the existence of a mobility deficit and whether it impairs participation in mobility-related activities of daily living. 

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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services (procedure code 99214) provided to the 
enrollee on March 25, 2021, and May 17, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the diagnosis billed was not appropriate in this case. 
 
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 99214 is "Office or other outpatient visit for the 
evaluation and management of an established patient, which requires a medically appropriate history and/or 
examination and moderate level of medical decision making. When using time for code selection, 30-39 
minutes of total time is spent on the date of the encounter." 
 
We find that CPT code 99214 is not supported in the medical record. Specifically, the diagnosis code used as 
the primary code in this case - F06.30 (mood disorder due to known physiological condition, unspecified) is not 
known as an appropriate primary diagnosis code.  
 
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 pay for telehealth services (procedure code 99214) 
provided to the enrollee on March 25, 2021, and May 17, 2021.