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

We decided that the Plan does not have to pre-approve Vertiflex device.
You asked the Plan to pre-approve Vertiflex 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 device. 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 low back pain and neurogenic claudication. The Vertiflex device 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 Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex device.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90832) provided on May 6, 2021.
You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. Medicare rules say that the clinical psychologist (CP) will attempt to
consult with the enrollee's attending or primary care physician.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of psychotherapy services have not been met. Specifically, the provided records do not document an
attempt to consult with the enrollee's attending or primary care physician. Therefore, we decided that the Plan
does not have to pay for psychotherapy services (90832) provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nasopharyngoscopy.

You asked the Plan to pre-approve nasopharyngoscopy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this 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 nasopharyngoscopy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the expectation that the enrollee will benefit from this procedure is not well supported in the medical literature. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nasopharyngoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve nasopharyngoscopy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant and a crown for tooth #30.
You asked the Plan to pay for the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered service.
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 an implant and a crown for tooth #30.
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 enrollee needs intensive therapies to optimize mobility and regain the ability to perform activities of daily living. The Plan denied your request. The Plan says the enrollee does not require intensive multidisciplinary approach to daily therapy.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for a lumbar fusion. Her medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve a home ventilator. You say that this equipment is medically necessary. The Plan denied your request. The Plan says the criteria for the requested ventilator have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our reviewer says that the requested item is not medically reasonable and necessary.
Our physician reviewer found a home ventilator is not medically necessary. This patient has a diagnosis of COPD listed, but there are no pulmonary function tests to confirm. The patient was recently hospitalized with heart failure and pulmonary edema, and hypercarbic respiratory failure. The patient has known obstructive sleep apnea and has been noncompliant with positive airway pressure therapy in the past. It appears this patient's needs could be met with bilevel positive airway pressure (BiPAP). There is no evidence of BiPAP failure. Medicare does not cover a ventilator when used as BiPAP. Certain BiPAP devices can provide the average volume-assured pressure mode of support. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the x-ray of the hand you had on May 24, 2021, and the x-rays of the fingers you had on June 7, 2021, and June 21, 2021.
You asked the Plan to waive the copayments for the x-rays. You say that you cannot afford these copayments and that you feel as though you pay enough for insurance. The Plan denied your request. The Plan says these copayments were charged correctly. The Plan says that the allowed amounts for the x-ray of the hand ($35.45) and the x-rays of the fingers ($36.38, each) are less than your copayment obligation, so you are responsible for the full allowed amount for each service.
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 $45 copayment for x-rays. You have been asked to pay a $45 copayment for the x-rays. 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 copayments for the x-ray of the hand you had on May 24, 2021, and the x-rays of the fingers you had on June 7, 2021, and June 21, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the colonoscopy (45380) provided on March 23, 2021.
You asked the Plan to pay for the colonoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the Plan paid the full value of the highest valued procedure (CPT code 45385), plus the difference.
The Plan must follow Medicare rules. Medicare rules say that for multiple endoscopies, pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the colonoscopy have not been met. Specifically, the record indicates that the Plan has paid for the highest valued endoscopy plus the difference between the next highest and the base endoscopy. Therefore, we decided that the Plan does not have to pay for the colonoscopy (45380) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Accu-Chek test strips for the enrollee.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says the covered supplies are covered through the plan's retail pharmacies.
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 test strips. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested test strips are a non-covered benefit. The plan has covered supplies available at both retail and mail order pharmacy supply vendors. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Accu-Chek test strips for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Freestyle Libre sensors (K0553) provided on March 17, 2021.
You asked the Plan to pay for Freestyle Libre sensors. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a recent physician order or relevant medical records which support medical necessity for the supplies provided in this case. The physician order provided is greater than 6 months old. The provided medical records do not discuss the need for a Freestyle Libre or associated supplies. 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 Freestyle Libre sensors (K0553) provided on March 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA).

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. She has had two sets of bilateral radiofrequency ablation (RFA) at L4, L5, and S1 within the past 12 months. The request for another set of RFA exceeds the limit set in the Medicare rules and is 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 repeat radiofrequency ablation (RFA).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit, as the height adjustment feature is a convenience feature.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the available medical evidence is not quality enough to show if the procedure is safe and helpful.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. High failure rates have been reported with similar devices. More research is needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services (99284), and services provided between 10:00 pm and 8:00 am at a 24-hour facility (99053) provided on March 10, 2021.
You asked the Plan to pay for the emergency department services and services provided between 10:00 pm and 8:00 am at a 24-hour facility. You say that the member was seen twice by two providers and the claims should be reprocessed. The Plan denied your request. The Plan says the claims have denied correctly.
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, we have confirmed that code 99284 has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. In addition, we find that CPT code 99053 is not eligible for payment. Specifically, CPT code 99053 has a status indicator of B meaning that payment for this service is always bundled into another procedure. Separate payment is not made for CPT code 99053. Therefore, we decided that the Plan does not have to pay for the emergency department services (99284), and services provided between 10:00 pm and 8:00 am at a 24-hour facility (99053) provided on March 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on May 22, 2021.
You asked the Plan to waive the copayment for the urgent care visit. You say that this visit was for Coronavirus testing, so there should be no copayment. You said that you had this testing twice before and it was provided at no cost. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that the costs for the Coronavirus testing were covered in full, but you were charged for an office visit at the urgent care center as well. The Plan says that because the allowed amount for this service ($37.27) is less than your copayment obligation, you are responsible for the full allowed 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 $50 copayment for urgent care services.
You have been asked to pay a $50 copayment for the urgent care visit. 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 urgent care visit you had on May 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient injection procedure you had on February 15, 2021.
You asked the Plan to waive the copayment for the outpatient injection procedure. You say that you don't believe you should have to pay this copayment since this procedure was needed due to an error by the hospital. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $375 copayment for outpatient surgery. You have been asked to pay a $375 copayment for the outpatient injection procedure. This copayment applies regardless of the reason for the procedure. 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 outpatient injection procedure you had on February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on June 2, 2021.
You asked the Plan to pay for the dental service. You say that the dental advised that they accept your insurance. You also say that you feel that this service should be covered. The Plan denied your request. The Plan says 1 emergency oral evaluation is covered every 12 months. 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. Though the Plan offers a dental benefit in excess of Medicare coverage and emergency oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for an emergency oral evaluation that you received on May 25, 2021. Therefore, we decided that the Plan does not have to pay for the emergency oral evaluation (D0140) provided on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for radiation therapy you received from May
3, 2021, to May 28, 2021.
You asked the Plan to waive the copayments for the radiation therapy. You say that you were given too much
radiation prior to your admission which resulted in extensive medical bills and having to wear a catheter. The
Plan denied your request. The Plan says you were charged these copayments correctly.
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 $25
copayment per visit for radiation therapy. We decided that the Plan does not have to waive the copayments for radiation therapy you received from May
3, 2021, to May 28, 2021.
You asked the Plan to waive the copayments for the radiation therapy. You say that you were given too much
radiation prior to your admission which resulted in extensive medical bills and having to wear a catheter. The
Plan denied your request. The Plan says you were charged these copayments correctly.
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 $25
copayment per visit for radiation therapy.
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 transfer to an IRF is medically necessary for this
enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The
enrollee's care can be provided in an alternate setting.
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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
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.