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

We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator
electrode (63650).

You asked the Plan to pre-approve the percutaneous implantation of neurostimulator electrode (63650). You
say that you are requesting a standard appeal of the denial of a spinal cord stimulator. The Plan denied your
request. The Plan says the request does not meet medical requirements.

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 percutaneous implantation of
neurostimulator electrode (63650). Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the criteria has not been met as
there is no psych evaluation.

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 percutaneous implantation of neurostimulator electrode (63650) have not
been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of
neurostimulator electrode (63650).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0364) received on January 19, 2021; to pay for endodontic therapy (D3330) received on June 4, 2020, and January 19, 2021; and to waive the cost sharing for a limited oral evaluation (D0140) performed on June 4, 2020.
You asked the Plan to pay for these dental services and adjust the cost share for these dental services. You stated that you were told the denied services would be covered. The Plan denied your request. The Plan says the services provided are not covered benefits and/or you reached your dental benefit limit. We partially overturned the Plans decision as there was required information missing from the case file. The Plan requested a reopen and provided the missing information.
Based on the information submitted, the Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Based on the Plan contract information and the claim information submitted with the reopen, the Plan is not required to pay for endodontic therapy (D3330) or waive the cost sharing for a limited oral evaluation (D0140). The Plan has now confirmed that endodontic therapy is not part of your dental benefit. The Plan also confirmed the limited oral evaluation on June 4, 2020, caused you to reach the yearly maximum for the dental benefit. It was noted that we previously decided the cone beam CT scan was not a covered benefit.
Therefore, it is now our decision that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0364) received on January 19, 2021; to pay for endodontic therapy (D3330) received on June 4, 2020, and January 19, 2021; and to waive the cost sharing for a limited oral evaluation (D0140) performed on June 4, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from February 27, 
2020 to March 1, 2020.

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 the submitted records do not support the billing of DRG 871 and principal diagnosis 
code A41.9.

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 871 and principal diagnosis A41.9 (sepsis, 
unspecified organism). 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 these services. Our 
reviewer says that the submitted records do not support the billing of DRG 871 and principal diagnosis code 
A41.9. Our physician reviewer found the records support an admission for pneumonia but is unclear regarding 
a diagnosis of sepsis. Although sepsis is documented in the medical record, there is no supporting 
documentation. Chest x-ray in the emergency room showed questionable infiltrate and the enrollee was 
admitted for shortness of breath and exacerbation of chronic obstructive pulmonary disease (COPD). The 
records do not support the billing of diagnosis code A41.9. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from February 27, 2020 to March 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic parenteral drug (D9610) provided on August 
19, 2021.

You asked the Plan to pay for the therapeutic parenteral drug. You say that because of the injection, a general 
anesthetic is necessity. You also say that an injection of Zofran was needed for nausea. The Plan denied your 
request. The Plan says this service is not a covered benefit under the enrollee's dental plan.

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 
therapeutic parenteral drug (D9610) provided on August 19, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility
to a skilled nursing facility for the enrollee.
You asked the Plan to provide coverage for this transfer. You say that this transfer was necessary as the
enrollee required additional care. The Plan denied your request. The Plan says the enrollee was receiving the
required care at the IRF facility. We overtured the Plan denial stating skilled nursing facility services
would be appropriate for the enrollee. The Plan requested a reopen and stated that the information in the case
file shoes the enrollee was receiving skilled nursing services at the inpatient rehabilitation facility (IRF). There
was no medical necessity for transfer to a SNF as an IRF is a higher level of care. There was no documentation
in IRF medical records that enrollee could not participate in the provided IRF-level of care. The enrollee was
seeing benefit from the therapy provided and was given care for complex medical needs.
The Plan is correct in this case. 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. The
medical records show the enrollee was receiving all the services provided in a SNF as well as a higher level of
care that is provided in an IRF. There is no indication the SNF would have provided services that were not
available in the IRF. Medicare coverage criteria for this type of transfer were not met. Therefore, we decided
that the Plan does not have to provide coverage for transfer from an inpatient rehabilitation facility to a skilled
nursing facility for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy/proton treatment delivery,
complex, for the enrollee.
You asked the Plan to pre-approve the services. You say that this is a Medicare-covered treatment and it is
medically necessary. The Plan denied your request. The Plan says a review of the current medical literature
indicates that the standard of care for radiation therapy for cancer of the tongue is standard radiation therapy
including Intensity modulated radiation therapy (IMRT).
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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found proton therapy has a role in the treatment of some cancer patients.
However, there are physical uncertainties about proton depth dose delivery which may make the actual
radiation deposition in tissue less conformal than it may appear based upon the treatment plan. There are
published studies on the use of proton therapy for head and neck cancer although proton therapy is not an
accepted standard. It is notable that proton therapy is being investigated in ongoing Phase III studies. Thus,
proton therapy is not an accepted standard of care for routine practice for typical locally advanced head and
neck cancers. For this case, no plan comparison is provided. Notably, this enrollee is to undergo ipsilateral neck
radiation for which IMRT would generally readily be able to spare critical normal tissues. Based upon the
provided records it is not plausible that proton therapy would provide a clinically meaningful benefit over a
well-designed IMRT plan. Thus, proton therapy is not necessary as it would not meet ASTRO or NCCN
criteria and therefore would not be furnished in accordance with accepted standards of medical practice.
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 proton beam therapy/proton treatment delivery, complex, for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pay for eyewear purchased at retail discount store on December 10, 2020.
You asked the Plan to pay for this eyewear. You say that this eyewear should be covered by the Plan. The Plan
denied your request. The Plan says you did not have prior authorization to use an out of network provider.
We overturned the Plans denial. The Plan requested a reopen and provided additional information. The
Plan noted that this provider is a commercial retailer and is not a Medicare eligible provider.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that no Medicare payment
may be made to a beneficiary for items or services provided directly by a vendor who is not a Medicare eligible
provider. You did not have prior authorization for this eyewear and the provider is not a Medicare eligible
provider. Therefore, we decided that the Plan does not have to pay for eyewear purchased on December 10,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital admissions and services.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested acute inpatient
hospital care is medically necessary. The Plan denied your request. The Plan says the requested acute inpatient
hospital care does not meet criteria.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the enrollee is undergoing a planned left reverse total shoulder
replacement. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List.
The procedure is currently approved as an ambulatory procedure. There is no documentation provided to
support the expectation the enrollee will require a greater than 2 midnight stay.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital admissions and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by an in-network
specialist on July 29, 2021.

You asked the Plan to waive the copayment for a specialist office visit. You say that you do not understand
why you have a copayment for the service because it was a preventative service. You say you believe the claim
should be paid in full by the Plan. The Plan denied your request. The Plan says the cost-sharing was applied
correctly in accordance with your contract. The Plan's network providers are grouped into different tiers with
different cost-share amounts. The Plan says the provider directory indicates you received services from a Tier 2
specialist.

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 $50
copayment for services obtained from a Tier 2 specialist.

You have been asked to pay a $50 copayment for a specialist office visit. Office visits fall within the
Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have
been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for an office visit provided by an in-network specialist on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) and the electrocardiogram (93000)
rendered by the out-of-network (OON) provider on May 20, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214) and the electrocardiogram (93000) rendered by the out-of-network 
(OON) provider on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on June 9, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says you do not have out-of-network benefits to reimburse for the refraction and therefore not reimbursed.

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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.

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 doctor's notes do not say if the last shot provided 80% pain relief.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have undergone two sessions of lumbar facet nerve block injections/medial branch blocks and reported only 50% relief of pain in the lower back. The requested radiofrequency ablation is not medically necessary or reasonable. 

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 radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 14, 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 the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on March 10, 2021.

You asked the Plan to pay for the services provided. You say that the services were medically necessary. The
Plan denied your request. The Plan says services are paid to the hospital.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and the rules. In this case, payment for the pathology services is the responsibility of the
hospital facility. 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 pathology
services provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided July 29, 2021.

You asked the Plan to pay for the diagnostic service. You say that you believe the denied codes for experimental is incorrect as these procedures were performed in accordance with the primary procedure code. The Plan denied your request. The Plan says experimental or investigational services are not covered. The intraoperative EEG in the setting of routine lumbar spinal surgery is unproven. Its clinical value has not been established.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file, and Medicare rules. An intraoperative EEG would be reasonable for monitoring cerebral function only during carotid artery or intracranial vascular surgery. Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for the intraoperative electroencephalogram (EEG) (95955) provided July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy (PT), and occupational therapy (OT), your rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility or in home with PT, OT, and wound care 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pre-approve radiofrequency ablation (CPT codes 64635, 64636 x2).
You asked the Plan to pre-approve radio frequency ablation. You say that this treatment is medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the
Plans denial. The Plan requested a reopen and stated that we did not apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare has specific coverage criteria
for radio frequency ablation. There is no documentation provided in the medical records to show the enrollee
had two diagnostic MBBs with documented pain relief from each service. Medicare coverage criteria were not
met at the time of the appeal. Therefore, we decided that the Plan does not have to pre-approve radiofrequency
ablation (CPT codes 64635, 64636 x2) to treat back pain.