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

 We decided that the Plan does not have to pay for a primary percutaneous transluminal mechanical thrombectomy (37185-76) provided on July 18, 2021.  You asked the Plan to pay for a primary percutaneous transluminal mechanical thrombectomy. You say that this was performed on two sites. The Plan denied your request. The Plan says this cannot be paid as billed.  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 37185-76 is primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure).  We find that CPT code 37185-76 is not supported in the medical record. Specifically, this is a second unit of an add-on code that was reported with one unit of the primary code. As this code refers to second and all subsequent vessels, it is not appropriate to report a second unit with one primary procedure. Based on this information, we decided that Medicare rules for coverage of a primary percutaneous transluminal mechanical thrombectomy have not been met. Therefore, we decided that the Plan does not have to pay for a primary percutaneous transluminal mechanical thrombectomy (37185-76) provided on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for arthrocentesis provided on August 31, 2021.  You asked the Plan to waive the copayment for arthrocentesis. You say that you received the service in a treatment room and disagree with the facility charges. 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 a $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   You received arthrocentesis on August 31, 2021, at an outpatient hospital facility. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $242.59, which is less than the $295 copayment.  You have been asked to pay $242.59 for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heart procedure (CPT code(s): 93924 and 93926) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee can receive the services with an in-network provider.  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 a heart procedure (CPT code(s): 93924 and 93926) to be provided by an out-of-network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Brovana (aformoterol) for use in a nebulizer.  You asked the Plan to pre-approve the Brovana treatment. You say that it is felt that this should be tried. The Plan denied your request. The Plan says a trial of Perforomist is required prior to approving Brovana.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Brovana treatment. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the patient has not been tried on Perforomist (formoterol). Both drugs are long-acting bronchodilators given by nebulizer. The Plan requires that Perforomist be tried first, and there is no evidence from the record that this has been done. There is no indication in the record of any adverse reactions to Perforomist or failure of treatment.   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 Brovana treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana (aformoterol) for use in a nebulizer.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says medical studies haven't proven that the device(s) is helpful for treatment of the enrollee's health problem.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device 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 services have not been met.       Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 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 does not meet criteria.  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 appears to be improving and only requires short-term additional acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed.    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 LTACH services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network provider.  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 medical record received did not show that you have an emergent or urgent medical condition or are in need of specialized service. The Plan states there are sixty (60) in-network provider(s) within a reasonable distance from your location that can provide this service/item.  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 nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a radiologic examination provided on October 29, 2021.  You asked the Plan to waive the copayment for a radiologic examination. You say that the provider billed wrong you went to an urgent care enter not the main hospital. The Plan denied your request. The Plan says the providers office verified and billed the services provided in an outpatient hospital and not urgent care center. Therefore, the proper copayment was 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 $85 copayment for Basic Radiological Services in an Outpatient Hospital. The total amount allowed was $76.96 which is less than the copayment amount of $85. Therefore, only $76.96 was charged as the copayment.    You have been asked to pay a $76.96 copayment for a radiologic examination. A radiologic examination falls within the Outpatient diagnostic tests and therapeutic services and 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 copayment for a radiologic examination provided on October 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a hip orthosis (L1686) and addition (L2624) provided on April 17, 2021.  You asked the Plan to pay for a hip orthosis and addition. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment 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 relevant medical records which support medical necessity for the supplies provided in this case. Specifically, the provided medical records do not address the need for the items at issue. 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 hip orthosis (L1686) and addition (L2624) provided on April 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4342 x4) provided on October 18, 2021.  You asked the Plan to pay for the scalings and planings. You say that you believe you should be reimbursed for these charges. The Plan denied your request. The Plan says you received four periodontal scalings and root planings (D4342 x4) which is why this code was billed four times. The Plan also says that you are responsible for a $60 copayment for each quadrant.  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, you are responsible for a $60.00 copay for each periodontal scaling and root planing (D4342). Therefore, we decided that the Plan does not have to pay for the four periodontal scalings and root planings (D4342 x4) provided on October 18, 2021.   Your complaint about the provider's possible up billing is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 5, 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 covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance ride provided by an in-network provider on September 18, 2021.  You asked the Plan to waive the copayment for the ambulance ride. You say that you believe the service was for coronavirus treatment and therefore you should have no patient liability. The Plan denied your request. The Plan says you have been asked to pay 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 $270 copayment for Medicare-covered ambulance benefits.   You have been asked to pay a $270 copayment for the ambulance ride. The ambulance ride falls within the "Ambulance services" benefit category. The medical record shows a diagnosis of abnormal labs and a pulmonary embolism. 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 ride provided by an in-network provider on September 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.      We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility or in home with services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (R0070) provided on July 6, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.  The Plan must follow Medicare rules. Medicare rules say that the transportation HCPCS R0070 or R0075 must be billed in conjunction with the CPT radiology codes. No transportation charge is payable unless the portable x-ray equipment used was actually transported to the location where the x-ray was taken.   We looked at the file and Medicare rules. In this case, the documentation provided does not show that the provider billed the transportation code on the same claim as the radiology codes. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (R0070) provided on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.  You asked the Plan to pre-approve the CT scan. You say that the test is needed to rule out diverticulitis. The Plan denied your request. The Plan says there are no signs or symptoms of acute worsening of the enrollee's condition.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 CT scan. Our physician reviewer found that the enrollee has chronic daily diarrhea. Prior endoscopic and colonoscopy testing in 2019 was performed as part of the workup for the diarrhea and revealed uncomplicated diverticula with appearance suggestive of possible irritable bowel disease. Recent examination findings were unremarkable, with no abdominal tenderness or fever. There was no reported blood in stool, vomiting, distention, no mass, no guarding/rebound tenderness, or other factors that might support imaging at this time. Based on the provided documentation, there was insufficient support made to show a CT was indicated at this time. Therefore, the CT will be considered 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen and pelvis.
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 is unsafe at home. The Plan denied your request. The Plan says the enrollee's needs can be provided on an intermittent basis.  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 respiratory failure, coronavirus pneumonia, and dehydration. There is ongoing weakness. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ProText/Wharton's Jelly injection rendered on September 7, 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 were 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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a past medical history of chronic pain syndrome and right ankle pain.    The ProText/Wharton's Jelly injection is considered experimental/investigational in nature based on current recommendations in the medical literature and Medicare-approved drug compendia. The services were 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 pay for the ProText/Wharton's Jelly injection rendered on September 7, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional x-ray (71045) provided on September 1, 2021.  You asked the Plan to pay for an additional x-ray. You say that this service was performed. The Plan denied your request. The Plan says an additional unit is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that an additional unit of CPT code 71045 is not supported in the medical record. The medical record only supports one unit of CPT code 71045, which was previously billed and paid. Based on this information, we decided that Medicare rules for coverage of an additional x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an additional x-ray (71045) provided on September 1, 2021.