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

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary
for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex procedure is experimental. More research is needed to show safety and
efficacy.

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a walker (99070) provided February 6, 2021.  You asked the Plan to pay for the walker. You say that the walker was medically necessary. The Plan denied your request. The Plan says the walker was not ordered by the treating physician.  The Plan must follow Medicare rules. The rules state that DME is covered only when there are both a physician order and proof of delivery.      The record does not contain a valid physician order which supports medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a walker (99070) provided February 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve AmnioCyte Plus injections (CPT code Q4242 x2) for the enrollee.  

You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says there is not enough information in the medical journals that these stem cell injections are helpful for the enrollee's condition.  

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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient support made for using stem cell treatments in a standard format for knee osteoarthritis. Also, the enrollee has not exhausted other more proven and conservative methods of treatment. Therefore, this request for stem cell injections will be considered 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 the injections have not been met. Therefore, we decided that the Plan does not have to pre-approve AmnioCyte Plus injections (CPT code Q4242 x2) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on May 18, 2021, to May 21, 2021.  

You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not know that you would have a copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $200 copayment for inpatient hospital care.   

You have been asked to pay a $200 copayment for an inpatient hospital stay. an inpatient hospital stay falls within the inpatient hospital care 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 inpatient hospital stay provided by a participating provider on May 18, 2021, to May 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services (97530, 97112, 97140) provided on July 22, 2021.  You asked the Plan to waive the copayment for the PT services. You say that you disagree with this copayment. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract. Physical therapy services require a $60 copayment when received from an out-of-network provider.  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 $60 copayment for out-of-network physical therapy visits.   You have been asked to pay a $60 copayment for the PT services, which were received from an out-of-network provider. 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 physical therapy (PT) services (97530, 97112, 97140) provided on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the surgical extraction (D7210) provided on August 12, 2021. 

 You asked the Plan to pay more for the surgical extraction. You say that you were advised by your insurance company that there would be no out-of-pocket charge. You also say that you are on a fixed income and paying for this service was not in your budget. The Plan denied your request. The Plan says your benefit maximum has been reached. 

 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 Plan offers a $2,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit while processing this claim for the August 12, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the surgical extraction (D7210) provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve services to be provided by an out-of-network (OON) provider.  

You asked the Plan to pre-approve these OON services. 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 a covered benefit.  

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 services to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6539.  

You asked the Plan to pre-approve the compression stockings. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested items are not a covered benefit.  

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6539 are noncovered because they do not meet the statutory definition of a surgical dressing.    

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6539.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two biologic materials to aid in soft and osseous tissue regeneration (D3431 x2).  

You asked the Plan to pre-approve the biologic materials. You say that you do not have the money to pay for these services. The Plan denied your request. The Plan says this service is not covered under your benefit 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 pre-approve two biologic materials to aid in soft and osseous tissue regeneration (D3431 x2).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Intracept procedure.  

You asked the Plan to pre-approve Intracept procedure. 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 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 enrollee has extensive degenerative disc disease and a broad-based bulge at L3-4 and a large central and right paracentral disc protrusion at L4-5 with progression which touches the L5 nerve root. The Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the enrollee does 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home visit provided on June 15, 2021 by an out-of-network (OON) provider.  

You asked the Plan to pay for the home visit provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  

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 home visit provided on June 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve a tertiary level referral with a head and neck surgeon.  

You asked the Plan to pre-approve the services. You say that you are undergoing cancer treatment and need a special neck and face surgery and skin graft. The Plan denied your request. The Plan says that a tertiary care center is not required.  

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the available clinical documentation, the requested services for tertiary care center referral meet criteria for being medically reasonable and necessary. You have evidence of oral cancer of the buccal mucosa. Though extent of disease, patient comorbidities, and other factors can influence the treatment pathway, surgery is frequently the treatment of choice for this type of lesion. Depending on the size of the excision, skin grafting or other types of tissue transfer may be necessary to close the defect effectively. These techniques are more complex and more frequently performed at tertiary care centers, which tend to have higher overall surgical volumes. In turn, high surgical volumes in head and neck oncology are associated with improved survival rates and other clinical outcomes.  In summary, the requested services for tertiary care center referral meets criteria for being medically reasonable and necessary to manage your cancer.  

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 been met. Therefore, we decided that the Plan has to pre-approve a tertiary level referral with a head and neck surgeon.   

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the additional radiologic examination (71045) provided on April 22, 2021.  You asked the Plan to pay for code 71045. 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 must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. In this case, there were no medical records provided confirming that two separate radiologic examinations (71045) were provided April 22, 2021 by the same provider. The file shows that the Plan paid for one radiologic examination (71045) provided by this provider on April 22, 2021. Therefore, we decided that the Plan does not have to pay for the additional radiologic examination (71045) provided on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Incision and removal of foreign body (10120) provided on August 6, 2021.  

You asked the Plan to pay for code 10120. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 10120.  

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 10120 is Incision and removal of foreign body, subcutaneous tissues; simple.  

We find that CPT code 10120 is not supported in the medical record. Specifically, the records provided do not document the removal of a foreign body. Based on this information, we decided that Medicare rules for coverage of code 10120 have not been met. Therefore, we decided that the Plan does not have to pay for the Incision and removal of foreign body (10120) provided on August 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the pigmentation tattooing provided by a provider who has not enrolled in the Medicare program on August 12, 2021.

You asked the Plan to pay for the pigmentation tattooing. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider is not enrolled in the Medicare program.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the pigmentation tattooing provided by a provider who has not enrolled in the Medicare program on August 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physical therapy (PT) services (97110, 97140, G0283, 97035) provided on November 11, 2020.

You asked the Plan to waive the deductible for the PT services. You say that this claim was processed in error, as you had previously satisfied your 2020 deductible for the year. The Plan denied your request. The Plan says this claim was processed correctly, and you had not met your 2020 deductible prior to these therapy services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $195 deductible which applies to outpatient rehabilitation services. 

The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $195 deductible which applies to outpatient rehabilitation services. Documentation shows that you were asked to pay $81.29 toward your deductible for the services provided on November 11, 2020. You previously paid $19.57 toward your deductible for services provided on August 17, 2020, and you were also asked to pay $94.14 toward your deductible for services provided on November 4, 2020 ($19.57 + $81.29 + $94.14 = $195). The claims for November 4, 2020, and November 11, 2020, were processed on the same date. The record shows that you had not met your 2020 deducible prior to these services, and the deductible was applied correctly.

This cost sharing is a contractual obligation that had not been met at the time the PT services were received on November 4, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the physical therapy (PT) services (97110, 97140, G0283, 97035) provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for DME and related supplies provided on April 29, 2021.  

You asked the Plan to waive the coinsurance for DME and related supplies. You say that you do not understand the additional charges because you already paid for the supplies you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for DME and related supplies.   

The record shows that you received DME and related supplies from a DME supplier on April 29, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $373.32 and 20% of that is $74.66.

   You have been asked to pay the total coinsurance amount of $74.66 for DME and related supplies. DME and related supplies fall within the DME and related supplies 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 coinsurance for DME and related supplies provided on April 29, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided August 6, 2021.  You asked the Plan to pay for the ambulance transportation. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis code.  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 A0425, & A0428 is not supported in the medical record. Specifically, R65.21 is not a valid primary diagnosis code. The underlying infection must be coded first when sepsis is present. Based on this information, we decided that Medicare rules for coverage of the ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for ambulance transportation (A0425, A0428) provided August 6, 2021.