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

We decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of neck (70498) and a CTA of head (70496).
You asked the Plan to pre-approve a CTA of neck and a CTA of head. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 a CTA of neck and a CTA of head. Our reviewer says that the services are not medically necessary. Our physician reviewer found absent at least any clinical symptoms suggestive of carotid stenosis or neurological deficit and without a family history of intracerebral aneurysm the medical necessity of CTA of the neck and head has not been established. 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 CTA of neck and a CTA of head have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomographic angiography (CTA) of neck (70498) and a CTA of head (70496).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the member does not have complex nursing or medical needs requiring
a resource intensive inpatient hospital 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and
Todd's paralysis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation
needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a
need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation
services. Medically necessary care can be provided in a different level of care. There is not a reasonable
expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for IRF 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI and coinsurance for an injection provided by a participating provider on September 22, 2020.
You asked the Plan to waive the copayment for an MRI and coinsurance for an injection. You say that this was the same procedure, and you should not be charged twice. The Plan denied your request. The Plan says the correct copayment and coinsurance 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 $110 copayment for outpatient diagnostic tests/radiological diagnostic services and a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a $110 copayment for an MRI and a 20% coinsurance of the allowed amount for injection. The total allowed amount is $21.30. The amount you are being asked to pay for an injection is $4.26 ($21.30 x 20% = $4.26). The total amount you are being asked to pay is $224.26 ($220 ($110 x2 MRIs = $220) + $4.26 = $224.26). An MRI falls within the outpatient diagnostic tests/radiological diagnostic services benefit category and an injection falls within the Medicare Part B prescription drugs 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 MRI and coinsurance for an injection provided by a participating provider on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network (OON) services at the in-network benefit level.

You asked the Plan to pre-approve the OON services at the in-network benefit level. You say that the OON provider you are requesting in-network coverage for is not a home health agency. You say that this provider supplies a range of physician supervised medically necessary services to homebound patients. You say that the in-network providers the Plan has references as an option for you, do not supply home, post-acute care that is supervised by a physician or nurse practitioner. You say that, for this reason, the Plan should be required to pay the non-contracted provider at the contracted rate, as the services are not available from preferred providers. The Plan denied your request. The Plan says the enrollee has a PPO plan that allows the use of OON providers, but with a higher copayment amount. The Plan says that there are in-network providers who can provide the services needed.

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 enrollee's can receive medically necessary services from out of network providers, but that the share of the costs for the covered services may be higher. The rules also say that plans must arrange for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs.

You have been told that the Plan will not pre-approve the OON services at the in-network benefit level. The records provided did not demonstrate that the services available within the Plan's network of providers would be inadequate in meeting your medical needs. The Plan has not denied the OON services. The Plan has stated that, should you choose to use the OON provider, the OON level of benefits would be applied. 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 pre-approve out of network (OON) services at the in-network benefit level.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthoses (L1833 and L2397) provided on September 8, 2020.
You asked the Plan to pay for knee orthoses. You say that you would like reconsideration because the orthoses are medically necessary. The Plan denied your request. The Plan says there is no claim history from the prescribing provider in the last 6 months prior to the date of service.
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 knee orthoses. 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 documentation of an appropriate evaluation of the enrollee, and there is insufficient credible objective documentation of joint laxity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of knee orthoses have not been met. Therefore, we decided that the Plan does not have to pay for knee orthoses (L1833 and L2397) provided on September 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (85060) provided on October 8, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.
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, code 85060 has a PC/TC indicator of "8" meaning that payment may not be made if furnished to hospital outpatients or non-hospital patients. Based on this information, we decided that Medicare rules for coverage of the interpretation of blood typing testing have not been met. Therefore, we decided that the Plan does not have to pay for the services (85060) provided on October 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that you need physical therapy to help with your chronic pain and treatment. The Plan denied your request. The Plan says the denial of authorization for additional therapy is correct, because this additional therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the records provided, there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. You appear you have improved with therapy to the point of being able to manage your activities of daily living with improved range of motion and strength. Further formal therapy at this point does not appear to be likely to achieve any significant improvement with your symptoms or functional status. Further utilization of the home exercise program is appropriate at this point. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthrocentesis, aspiration and/or injection (20610), the methylprednisolone acetate injection (J1040), and the lidocaine injection (J2001) rendered by the out of network (OON) provider on August 13, 2020.
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 arthrocentesis, aspiration and/or injection (20610), the methylprednisolone acetate injection (J1040), and the lidocaine injection (J2001) rendered by the out of network (OON) provider on August 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically necessary for the enrollee. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient 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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visit for the evaluation and management of an established patient (99213) provided December 4, 2020.
You asked the Plan to waive the copayment for the office visit. You say that the insurance wanted you to be seen by the provider and have an MRI before your appointment to receive an injection. The extra appointment was useless and you should not be charged for it. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $40 copay for each covered specialist office visit. You have been asked to pay $40 copay for the office visit. The office visit falls within the Physician/Practitioner services, including doctor's office visit benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office visit for the evaluation and management of an established patient (99213) provided December 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional Right RFA at L3-5 (CPT code(s): 64635 and 64636), 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 the enrollee previously had five (5) facet joint injection sessions, including four medial branch block sessions and one radiofrequency ablation session, since October 22, 2020. The Plan states this request is denied in that the enrollee has exceeded the limit of five injection sessions per region per year. The Plan states the enrollee will not be eligible for another session until after October 22, 2021.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee already received five (5) facet joint injection sessions, including four medial branch block sessions and one radiofrequency ablation session, since October 22, 2020. The rules say that a maximum of five (5) facet joint injection sessions inclusive of medial branch blocks, intraarticular injections, facet cyst rupture and RF ablations may be performed per rolling 12 month year in the cervical/thoracic spine and five (5) in the lumbar spine. Therefore, we decided that the Plan does not have to pre-approve additional Right RFA at L3-5 (CPT code(s): 64635 and 64636), for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a Cardiac PET Absolute Quantitation of Myocardial Blood Flow (AQMBF).
You asked the Plan to pre-approve a Cardiac PET AQMBF. You say that the requested Cardiac PET AQMBF is medically necessary. The Plan denied your request. The Plan says that the requested Cardiac PET AQMBF is not medically necessary.
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 a Cardiac PET AQMBF. Our reviewer says that the requested Cardiac PET AQMBF is medically necessary. Our physician reviewer found the enrollee is status post bariatric surgery and she has a known history of coronary artery disease and is status post coronary stenting several years ago. She has symptoms which could be consistent with ischemia and already underwent nuclear stress testing which was unfortunately an inconclusive study possibly due to attenuation artifact. Cardiac PET CT has been shown to provide additional diagnostic clarity when SPECT nuclear imaging is inconclusive and is a very reasonable and necessary medical study in this situation, especially given the ongoing symptoms and known history of CAD. A conclusive cardiac PET CT could also obviate the need for repeat invasive coronary angiography. The cardiac PET CT therefore meets criteria as safe, effective, medically reasonable, not investigational and is medically necessary in this clinical situation. 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 Cardiac PET AQMBF have been met. Therefore, we decided that the Plan has to pre-approve a Cardiac PET Absolute Quantitation of Myocardial Blood Flow (AQMBF).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Zoster (shingles) vaccine services received on August 26, 2020.
You asked the Plan to pay for the Zoster (shingles) vaccine services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Zoster (shingles) vaccine services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the Zoster (shingles) vaccine services. Therefore, we decided that the Plan does not have to pay for the Zoster (shingles) vaccine services received on August 26, 2020.
Benefits for the Zoster (shingles) vaccine services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wig (CPT code A9282).
You asked the Plan to pre-approve the wig. You say that you are requesting review of denial of services. The
Plan denied your request. The Plan says Medicare criteria for medical supplies do not cover wigs. Wigs are for
comfort and to improve appearance. Neither Medicare nor your health plan covers wigs.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve the wig (CPT code A9282).
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. The Plan denied your request. The Plan says there are no skilled nursing or therapy needs 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 physician reviewer found that you were admitted to the hospital with gastrointestinal bleeding and anemia. There are no required skilled nursing services identified. You are expected to benefit from skilled therapy services, but the documentation does not support the need for skilled therapy on a daily basis in an inpatient 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on October 6, 2020. You asked the Plan to pay for the shingles vaccine. You say that you were not informed the cost was not covered. The Plan denied your request. The Plan says the service is not covered under your contract.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. The records do not show that you were injured or directly exposed to any illness related to the shingles vaccine.Therefore, we decided that the Plan does not have to pay forthe shingles vaccine provided on October 6, 2020.Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.