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

 
We decided that the Plan does not have to pay for the chest x-ray rendered on September 20, 2020. 
 
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 procedure code 71045 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 71045 and 71046. Code 71045 is a column II code with a 
modifier indicator of 1 when billed with column I code 71046. Code 71045 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the chest 
x-ray rendered on September 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 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. The enrollee 
was admitted for surgical treatment of a hip fracture after a fall. Medical conditions are stable. There are no 
medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for 
physical and occupational therapy, it does not document a need for an intensive 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.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. The patient appears to not be stable enough to transfer due to fevers and encephalopathy and requires additional acute care services which can safely be performed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee
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 IRF admission is medically necessary. The Plan 
denied your request. The Plan says your needs can be met at a different level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 based on the medical records provided the complexity of your nursing, medical and 
rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to 
rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the 
medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF level of 
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee. You asked the Plan to pre-approve acute inpatient hospital care. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. X-rays showed osteoarthritis and a rotator cuff tear. The enrollee is scheduled to undergo arthroplasty. The enrollee is stable and the required care is not expected to cross 2 midnights in the hospital setting based on the documentation provided. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for acute inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on October 9, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you should have been notified of 
any changes. You say that this should be paid 100%. The Plan denied your request. The Plan says the correct 
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 20% 
coinsurance for Medicare Part B prescription drugs/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $15.16. The total amount you are being asked to pay is $3.03 ($15.16 x 20% = $3.03). The correct 
coinsurance has been applied to the injection applied. An injection falls within the Medicare Part B prescription 
drugs/in-network benefit category. This means that you have been asked to pay the correct amount based on 
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for an injection 
provided by a participating provider on October 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System (CPT Code 33289). 
 
You asked the Plan to pre-approve the services. You say that the enrollee's quality of life is in danger. The Plan 
denied your request. The Plan says the services are considered experimental and investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this circumstance, therapy change based on data obtained from a CardioMEMs device has 
been demonstrated in only one randomized prospective trial to help reduce hospital readmission compared to 
standard medical therapy. Moreover, concerns have been raised about potential bias in this trial calling into 
question the results. Therefore, the efficacy of the CardioMEMS device is uncertain at this time according to 
leading authorities and not recommended in current guidelines for the treatment of heart failure. Medicare 
coverage criteria are not met, since the device should still be considered experimental or investigational. 
 
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 CardioMEMS HF System (CPT Code 33289).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. 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 follows Medicare rules. Medicare rules say that a repeat series* of hyaluronan knee injection(s) for patients who have responded to a prior series is considered to be reasonable and necessary under specific circumstances. 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 Synvisc. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that your symptoms have recurred and there has been at least six months have elapsed since the prior series of injections. There is no evidence of a significant improvement in pain and functional capacity achieved with the prior series of injections using a standardized assessment tool and there is no evidence of a significant reduction in the doses of nonsteroidal anti-inflammatory drugs (NSAID) medications taken or reduction in the number of intra-articular steroid injections to the knees during the six-month period following the injection(s). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral exam (D0150) and unspecified preventive procedure (D1119) provided October 7, 2020.You asked the Plan to pay forthe dental services. You say that your previous dentist closed his office and you needed to go to a new dentist. You needed to a comprehensive oral evaluation as a new patient and you believe the plan should pay for the evaluation.The Plan denied your request. The Plan says these services exceeds the benefit frequency limitations. The services is not covered under the plan benefits.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. The health plan contract covers 1 comprehensive exam every 3 years. The records show this service was provided February 22, 2019. Services not listed is not covered by the plan. 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 forthe comprehensive oral exam (D0150) and unspecified preventive procedure (D1119) provided October 7, 2020
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve absolute quantitation of myocardial blood flow 
(AQMBF) positron emission tomography (PET) scan. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered when specific criteria are 
met. 
 
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 submitted records show that the 
enrollee has some coronary risk but no chest pain, no acute ischemic electrocardiogram (ECG) changes, and no 
regional dysfunction on echocardiography. Screening stress testing of any sort has not been shown to improve 
cardiac outcome, even in high risk patients. In addition, if stress testing were thought to be medically necessary 
then dobutamine echocardiography should be effective and is considered safe in patients with non-severe aortic 
valve stenosis.  The records do not support the medical necessity for a cardiac PET scan. 
 
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 absolute quantitation of myocardial blood flow (AQMBF) positron emission tomography 
(PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) intraoral-complete 
series (D0210) provided. 
 
You asked the Plan to pay for the dental services. You say that you was not aware that this wold not be 
covered. You are appealing this bill of $245 and as if the x-rays taken be applied to the next date when the 
frequency limitation is not exceeded. The Plan denied your request. The Plan says these services exceeds the 
benefit frequency limitation. 
 
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. Comprehensive oral exams is 
covered once every 3 years. The records show that this service was provided. Complete 
series x-rays or panoramic x-ray is covered once every 5 years. The records show that a panoramic x-ray was 
provided. 
 
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 at this time. Therefore, we decided that the Plan does not have to pay 
for comprehensive oral evaluation (D0150) intraoral-complete series (D0210) provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays rendered on July 2, 2020. 
 
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 benefit limit was 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. The Plan covers bitewing x-
rays once every 12 months. 
 
We looked at the file and the Plans rules. The file shows that you previously received bitewing x-rays on June 
16, 2020 that the Plan covered. The bitewing x-rays on July 2, 2020 were performed more than once in a 12 
month period. Based on this information, we decided that the Plan's rules for coverage of these services have 
not been met. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays rendered on July 
2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to adjust the copayment for the inpatient skilled nursing facility care 
(SNF) provided from March 14, 2020, through April 11, 2020. 
 
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 for each admission you 
must pay $20 per day, for days 1-20 of a benefit period and $0 per day, for days 21?100 of a benefit period, for 
inpatient skilled nursing facility care.  
 
You have been asked to pay $440 ($20 copayment x 22 days) for the inpatient skilled nursing facility care 
provided. 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 adjust the copayment for the inpatient skilled nursing facility care (SNF) 
provided from March 14, 2020, through April 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on December 
14, 2019. 
 
You asked the Plan to waive the copay for the ambulance transport. You say that you did not need these 
services. The Plan denied your request. The Plan says that you are responsible for the copayment. 
 
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 $225 
copay per covered ambulance trip.  
 
You have been asked to pay a $225 copay for the ambulance transport. The ambulance transport falls within 
the covered ambulance trip 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 copay for the ambulance 
transport provided on December 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lead wires provided on September 25, 2020.
You asked the Plan to pay for lead wires. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that replacement of lead wires (A4557) more often than every 12 months is non-covered. We looked at the file and Medicare rules. Review of the file shows that the enrollee received a TENS unit with lead wires on June 25, 2020. Twelve (12) months had not passed since the enrollee last received lead wires. Based on this information, we decided that Medicare rules for coverage of lead wires have not been met. Therefore, we decided that the Plan does not have to pay for lead wires provided on September 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFasenra30 mg/ml syringe (J0517).You asked the Plan to pre-approveFasenra 30 mg/ml syringe. 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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Fasenra 30 mg/ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the Fasenra is medically reasonable and necessary or safe and effective for the enrollee. Records do not document continued disease improvement or lack of disease progression as evidenced by a reduction in asthma exacerbations (e.g. reduced use of rescue medications, reduced urgent care visits, reduced hospitalizations) or documentation of decreased oral corticosteroid use.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Fasenra 30 mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approveFasenra 30 mg/ml syringe (J0517).