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

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).

You asked the Plan to pre-approve the service. You say that you need this procedure right away because you have long-term back issues. The Plan denied your request. The Plan says your request is not medically necessary because your records show you have not had recent trials of other treatment modalities such as physical or psychological therapy, exercise trials, nor recent interventional pain treatments. The Plan states your medication history and other records describe current problems with depression. The Plan states your records do not document why you are not a surgical candidate.

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 service. Our physician reviewer found the NCD, and LCD requires psychological evaluation by either a licensed psychologist or a psychiatrist. A clinical social worker does NOT meet the criteria of the NCD and LCD. You do not have an evidence-based indication for a SCS trial. The documentation does not include a surgical consultation with an explanation of why you are not a surgical candidate. There is no documentation of recent conservative therapy. The request 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650).
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 stay is medically necessary. 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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency
transport (A0428) and ground mileage (A0425) provided on January 29, 2021.
You asked the Plan to pay for the ambulance services. You say that the enrollee was not enrolled in hospice
until after the ambulance transport was rendered. The Plan denied your request. The Plan says the enrollee's
claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on
the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the
provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing
procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. The hospice
benefit is based on the date of election and is not time specific. Therefore, we decided that the Plan does not
have to pay for the ambulance service, basic life support, non-emergency transport (A0428) and ground
mileage (A0425) provided on January 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on May 14, 2021.
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Cxbladder Detect (0013M) provided May 12, 2021.
You asked the Plan to pay for Cxbladder Detect. You say that you believe that the evidence supporting use of Cxbladder as a medically necessary diagnostic service is well established. The Plan denied your request. The Plan says this service is 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 looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cxbladder Detect have not been met.
Therefore, we decided that the Plan does not have to pay for Cxbladder Detect (0013M) provided May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on July
13, 2021.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says you have been charged 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 $250
copayment for each one-way ground ambulance trip. You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport 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. 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 ambulance transport provided on July 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dentures (D5213), provided on June 29, 2021.
You asked the Plan to pay for the dentures. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered 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. 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. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the dentures (D5213), provided on June 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 13, 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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 13, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled nursing or therapy services on a daily basis. 

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 skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the breast prosthesis (L8000), provided on May 1, 2021.
You asked the Plan to pay for the breast prosthesis. You say that the service should be covered. The Plan
denied your request. The Plan says that the claim was processed and paid correctly.
The Plan must follow Medicare rules. Medicare rules say that for services rendered by a non-contracting, nonparticipating
DME supplier, the MAO must pay the non-contracting non-participating (non-par) DME.
We looked at your request, the file and Medicare rules. Based on this information we determined that coverage
criteria for additional reimbursement have been met. Specifically, the record indicates that these supplies were
provided by a non-contracting, non-participating provider. The Plan is responsible for paying the difference
between the member's cost share and the amount billed by the provider. The member is only responsible for
they Plan-allowed cost sharing. Therefore, we decided that the Plan has to pay for the breast prosthesis
(L8000), provided on May 1, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device.

You asked the Plan to pre-approve Vertiflex Superion device. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested 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 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 you have low back pain. The vertilfex device is experimental. More research is needed to show safety and efficacy. Therefore, you do not meet criteria for the requested 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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the radiofrequency ablation. You say that you would like reconsideration because the requested radiofrequency ablation is medically necessary. The Plan denied your request. The Plan says the records show that the member has already had two radiofrequency sessions in the lumbar/sacral spine region in the past 12 months.
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 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 radiofrequency ablation. Our reviewer says that the request exceeds the frequency limitation. Our physician reviewer found the enrollee has already had two lumbar/sacral region radiofrequency sessions in the past year. 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on March 26, 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 the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on March 26, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2781, V2303, V2744, V2781, V2750) purchased on August 11, 2021.  You asked the Plan to pay for the eyeglasses. You say that these eyeglasses and upgrades are medically necessary. The Plan denied your request. The Plan says they have paid the $200 allowance for routine eyewear on the date of service, and you are responsible for the remaining cost, as it exceeded the allowance amount.  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 covers up to $200 per calendar year for eyeglasses, frames, lenses, or contact lenses from a participating network provider.  We looked at the file and the Plan's rules. Documentation shows that the total cost of the eyeglasses purchased on the date in question was $495. The Plan paid $200 of this cost, and you are being asked to pay the remaining $295. You have used the full benefit allowance for eyewear. Therefore, we decided that the Plan does not have to pay an additional amount for the eyeglasses (V2781, V2303, V2744, V2781, V2750) purchased on August 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve the skilled nursing facility services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 skilled nursing facility services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the record shows that the enrollee is medically stable without any acute exacerbations of chronic medical problems. Her physical function is at or near her baseline and she can receive services 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 the skilled nursing facility services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
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 physical therapy and occupational therapy is
recommended after discharge. The Plan denied your request. The Plan says the enrollee's records do not show
the enrollee does not require skilled nursing services or skilled rehabilitation services on a daily basis and
which can only be provided on an inpatient basis in a SNF. The Plan states the enrollee's rehabilitation and
medical needs can be met with part-time skilled services in a lower level of care, such as home with
supervision and home health services. The Plan states home health services will need to be approved by the
enrollee's health plan. The Plan states the enrollee's rehabilitation needs can safely be received at a different
setting, for example, home with home health, in residential care, or home with close follow-up with the
enrollee's doctor.
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 the enrollee has stabilized medically and is
ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy
services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a
lower level of care. Although further rehabilitation services would be appropriate to improve function, as a
practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The
enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The
enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's
physical function is at or near their baseline and the enrollee can receive services at a lower level of care.
Admission to a SNF for inpatient skilled rehabilitation 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine received on January 25, 2021.
You asked the Plan to pay for the Zoster (shingles) vaccine. You say that you didn't know you needed to get
this vaccine at the pharmacy. You also say that you would like the plan to reconsider their denial. The Plan
denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles)
vaccine. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Zoster
(shingles) vaccine. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine
received on January 25, 2021.
Benefits for the Zoster (shingles) vaccine may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights.