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

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transportation services (A0428HN, A0425HN) provided on February 26, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that the enrollee was admitted to this facility for a rehab program and was transported by ambulance because she was unable to walk. The Plan denied your request. The Plan says they have covered the non-emergency transportation, but the enrollee is still responsible for their share of the cost for services. The copayment is only waived if the enrollee is admitted to the hospital within three days for the same condition, but the enrollee was transported to a nursing facility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for ambulance services. The enrollee has been asked to pay a $200 copayment for the ambulance services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the non-emergency ambulance transportation services (A0428HN, A0425HN) provided on February 26, 2021.
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 the requested procedure is medically necessary. The Plan denied your request. The Plan says there are not enough studies to show that the Vertiflex device is safe and effective.
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 device is indicated for those patients with impaired physical function who experience relief in flexion from symptoms of leg/buttock/groin pain, with or without back pain, who have undergone at least 6 months of non-operative treatment. The Vertiflex device may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. In this case, the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurgenic claudication.
The record indicates that imaging has demonstrated moderate to severe spinal stenosis at L4-L5, the level requested for treatment. The record does not state that the enrollee is not indicated for operative therapy at more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you feel the requested services are medically necessary. The Plan denied your request. The Plan says the requested services are 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you received oral medications. You had stable vital signs. You required maximum assistance with bed mobility. The documentation does not support that you require skilled nursing services on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the genicular nerve block (64454) provided on May 20, 2020.
You asked the Plan to pay for the genicular nerve block (64454). You say that the genicular nerve block (64454) provided on May 20, 2020 was medically necessary. The Plan denied your request. The Plan says the genicular nerve block (64454) provided on May 20, 2020 was 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 pay for the genicular nerve block (64454). Our reviewer says that the genicular nerve block (64454) provided on May 20, 2020 was not medically necessary. Our physician reviewer found the enrollee was being treated for unilateral primary osteoarthritis, left knee. However, there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There are no exam findings provided (outside of the procedure report), to support going outside of recommendations. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the genicular nerve block (64454) provided on May 20, 2020 was 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 genicular nerve block (64454) have not been met. Therefore, we decided that the Plan does not have to pay for the genicular nerve block (64454) provided on May 20, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided the Plan has to pay for the acute inpatient hospital care provided from May 23, 2021, to May 25, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission was medically necessary. The Plan denied your request. The Plan says that Medicare criteria for inpatient care were not met.
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 pay for acute inpatient hospital care from May 23, 2021, to May 25, 2021. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the medical records show the enrollee had bladder cancer and was status post resection as well as several other health issues. The enrollee to the emergency room on May 23, 2001 with acute onset of hallucinations and confusion x 2 days. Due to acute mental status change, history was obtained from the family. The enrollee was afebrile without tachycardia, normotensive, saturating well on room air, no tachypnea. Emergency care included 1g IV Ceftriaxone then every 24 hours with gentle hydration overnight. She was admitted; her condition stabilized and improved, and she was discharged May 25, 2021. The records show at the time of inpatient admission the admitting physician reasonably expected that the necessary hospital care would span two midnights. 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 from May 23, 2021, to May 25, 2021 have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from May 23, 2021, to May 25, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records received show that your condition has improved and you are no longer a threat to yourself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary. It is not expected you would improve in a reasonable period of time as you do not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You do not show any abnormal behaviors or any symptoms which would require acute treatment. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as you do not have dangerousness to self or others but were compliant with your treatment. Our physician reviewer found that your condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80053, G0471, 85025) and the one
way travel allowance in connection with a medically necessary laboratory specimen collection drawn from a
home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network
(OON) provider on January 7, 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 laboratory services (80053, G0471, 85025) and the one way travel allowance in connection with a medically necessary laboratory specimen collection drawn from a home bound or nursing home bound patient; prorated trip charge (P9604) rendered by the out-of-network (OON) provider on
January 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records do not support the need for daily therapy on an inpatient basis.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter (E0118).
You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare in any payment system.
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 scooter. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you can safely and effectively maneuver the requested device. The documentation does not reveal a detailed neuromuscular or musculoskeletal exam indicating that you are unable to use her manual wheelchair. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter (E0118).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 29, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 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 out of network physician services provided to the enrollee on March 29, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 21, 2020.
You asked the Plan to pay for physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
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 dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on October 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by codes A4550, A4556, A4557, A4649, A9999, J7120, S1015, and S8301 provided on October 6, 2020.
You asked the Plan to pay for codes A4550, A4556, A4557, A4649, A9999, J7120, S1015, and S8301. 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 as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and Medicare rules. Code A4550 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to.
Codes A4556, A4557, and A4649 have a status code of "P" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment is bundled into the payment for the services to which these codes are incident to.
Code A9999 has a status code of "X" under the MPFSDB and represents a service that is not in the statutory definition of "physician services" for fee schedule payment purposes.
Code J7120 has a status code of "E" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for these codes under the fee schedule as payment for these codes are excluded from the physician fee schedule by regulation. This code can only be billed by the facility where the enrollee will have the approved procedure.
Codes S1015 and S8301 have a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and are not valid for Medicare purposes. Medicare uses other codes for reporting of, and payment for, these services.
Based on this information, we decided that Medicare rules for coverage of codes A4550, A4556, A4557, A4649, A9999, J7120, S1015, and S8301 have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services represented by codes A4550, A4556, A4557, A4649, A9999, J7120, S1015, and S8301 provided on October 6, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory work provided on April 15, 2021.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says that no prior authorization was obtained.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the correct Evidence of Coverage. This means we cannot determine if the Plan's denial of the non-emergent service is supported. Therefore, we decided that the Plan has to pay for laboratory work provided on April 15, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided May 11, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not ordered by the treating physician.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.
We looked at the file and Medicare rules. The plan has attested that the treating provider did not order this service. The records do not support that the service was ordered by the treating physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DyAnsys Implantable Neurostimulator, (64555, L8679).
You asked the Plan to pre-approve the implantable neurostimulator. You say that the enrollee requires this device and has exhausted alternatives. The Plan denied your request. The Plan says the requested service is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that devices used for electro-acupuncture are not covered by Medicare per Medicare Local Coverage Article (LCA) (A55240). Electro-acupuncture devices and implantable neurostimulators are two separate devices, and coding electro-acupuncture devices as implantable neurostimulators is incorrect. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the implantable neurostimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve DyAnsys Implantable Neurostimulator, (64555, L8679).