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

We decided that the Plan does not have to pay for the excision services coded 21933 provided on July 8, 2019.
You asked the Plan to pay for the excision services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 21933 is Excision, tumor, soft tissue of back or flank,
subfascial (eg, intramuscular); 5 cm or greater.
We find that CPT code 21933 is not supported in the medical record. Specifically, this code was not the most
appropriate service performed for the place of service of 11 (office). Based on this information, we decided that
Medicare rules for coverage of the excision services have not been met. Therefore, we decided that the Plan
does not have to pay for the excision services coded 21933 provided on July 8, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says that you are covered for up to 100 days each benefit period.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. We looked at the file and Medicare rules. The file shows that you were discharged on July 26, 2019. The file also shows that you were admitted on December 27, 2019. More than 60 days passed without inpatient hospital or SNF care. This means that a new benefit period began with the admission on December 27, 2019. Based on this information, we decided that Medicare rules for coverage of continued services have been met. The Plan must continue coverage for the SNF skilled service until such time as you no longer need the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast reduction surgery provided on October 16, 2019.
You asked the Plan to waive the copayment for the breast reduction surgery. You say that you would like the money back that you had to pay. The Plan denied your request. The Plan says you have been charged 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 $325 copayment for surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the breast reduction surgery. The breast reduction surgery falls within the "Outpatient surgery, including 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 the breast reduction surgery provided on October 16, 2019.
Your complaint about the doctor not addressing your concerns are 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane viscosupplementation injections.
You asked the Plan to pre-approve the Durolane injections. You say that this medication is necessary to treat the condition. The Plan denied your request. The Plan says the covered drugs for this treatment are Orthovisc or Monovisc.
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 Durolane injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on the step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. The enrollee has not tried the plan preferred drugs. The documentation does not support that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 Durolane injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane viscosupplementation injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane for the enrollee. You asked the Plan to pre-approve Durolane. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception. 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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc or that they would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Durolane. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a gene analysis of prostate tumor tissue (81551) provided on January 25, 2019 by an out-of-network provider. You asked the Plan to pay for a gene analysis of prostate tumor tissue. You say that you submitted additional documentation requested to review for the maximum allowed amount. The Plan denied your request. The Plan says out-of-network providers/members may obtain services from an out-of-network provider only when providers of specialized services are not available in-network or in urgent and/or emergent situations. To obtain authorization for a provider of specialized services that are not available in network, your primary care provider (PCP) will submit a referral request and any supporting documentation. For any urgent or emergent services, the care may be provided first, and then a claim for those services submitted to the Plan by the provider along with supporting medical documentation. 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 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. 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 a gene analysis of prostate tumor tissue (81551) provided on January 25, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that the enrollee require prolonged hospitalization and close physician monitoring.The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and doesnot require transfer.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 physician reviewer found that the enrollee was admitted to the acute hospital with delirium, hyponatremia, and sepsis related to lower extremity cellulitis.  He has had acute kidney injury, liver failure, coagulopathy, heart failure with an ejection fraction less than 20%. He has been treated in the intensive care unit with intravenous antibiotics. He has ascites and was intubated for respiratory failure. he is now on nasal cannulaoxygen and BiPAP. He has dysphagia and has been fed via a feeding tube. Based on the provided medical records,the enrolleeis getting the requiredservices in the present acute care hospital. Continued careat this level is appropriate. The acute care hospital is able to provide all of the services the enrolleerequires.We looked at this physician's review, the file, and Medicarerules. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ECG provided on September 16, 2019 by an out of network provider.
You asked the Plan to pay for an ECG. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
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 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. 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 an ECG provided on September 16, 2019 by an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot x-ray rendered on on August 30, 2019.
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 claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that procedure code 73630-26-RT was not billed with a diagnosis code to match the right-sided laterality. Therefore, we decided that the Plan does not have to pay for the foot x-ray rendered on on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician certification for Medicare-covered home health services under a home health plan of care G0180) provided on August 23, 2019 by the out of network provider.
You asked the Plan to pay for physician certification for Medicare-covered home health services under a home health plan of care. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 23, 2019. You say that this procedure does not need prior authorization. The provider reviewed the plan of care and signed off on the Home Health Certificate at an outpatient location. The Plan denied your request. The Plan says the referring provider and the rendering facility are non-participating providers. The plan did not authorize any services for the facility or physician. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 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. 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 physician certification for Medicare-covered home health services under a home health plan of care G0180) provided on August 23, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the services. You say that you have been going to this doctor for about a year. The Plan denied your request. The Plan says the services are available in-network.
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 pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy (43282), diaphragm resection (396560), and
partial gastrectomy (43631) provided on September 10, 2019.
You asked the Plan to pay for a laparoscopy, diaphragm resection, and partial gastrectomy. You say that these
codes are supported and were medically necessary. The Plan denied your request. The Plan says these codes are
not supported by the records.
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 43282 is laparoscopy, surgical, repair of paraesophageal
hernia, includes fundoplasty, when performed; with implantation of mesh; 39560 is resection, diaphragm; with
simple repair (eg, primary suture); and 43631 is gastrectomy, partial, distal; with gastroduodenostomy.
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 a laparoscopy, diaphragm resection, and
partial gastrectomy. Our reviewer says that CPT 43282 is not supported by the medical records. The operative
report does not describe repair of the paraesophageal hernia with implantation of mesh. There is no
documentation of implantation of mesh. Our reviewer also found that CPT 39560 is not supported by the
medical records. The operative note does not describe resection of the diaphragm with simple repair. The
documentation is of closure of a large gaping defect of the diaphragm using sutures. CPT 43631 is also not
supported by the medical records. The operative note does not describe partial distal gastrectomy with
gastroduodenostomy. It is documented that a gastrotomy was performed in order to decompress the stomach.
Once this was done, a partial gastrectomy was necessary in order to reseal the gastrotomy
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 laparoscopy, diaphragm resection, and partial gastrectomy have not been met.
Therefore, we decided that the Plan does not have to pay for a laparoscopy (43282), diaphragm resection
(396560), and partial gastrectomy (43631) provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sacroiliac (SI) joint injections rendered to the enrollee on June 21, 2019.
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 supported.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The file contains no documentation to support that the services were reasonable and medically necessary. 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 sacroiliac (SI) joint injections rendered to the enrollee on June 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 5,
2019.
You asked the Plan to pay for the drug testing services. You say that the services were medically necessary.
The Plan denied your request. The Plan says no clinical notes were sent for review.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering
physician's intent that the tests be performed. Based on this information, we decided that Medicare rules for
coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to
pay for the drug testing services provided to the enrollee on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee on August
29, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for this
service would be included in the Part A DRG payment to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all
necessary covered services to the beneficiary either directly or under arrangements made with outside
providers. Payment for all fees related to this service would have been included under the facility claim.
Therefore, we decided that the Plan does not have to pay for the services (CPT 99190) provided to the enrollee
on August 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral.
You asked the Plan to pre-approve these services. You say that the enrollee lives in Illinois half of the time and needs wound care over eight weeks. The Plan denied your request. The Plan says the services are not urgent or emergent and can be rendered by in-area, in-network providers.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. The file shows that the enrollee received emergency services while outside of the Plan's service area on November 28, 2019 for a heel wound. Follow-up care of nine visits over eight weeks was recommended. The file shows that the enrollee lives outside of the Plan's service area for part of the year and that the services are not urgent or emergent in nature, but routine follow-up care for the wound.
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 a referral.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips.You asked the Plan to pre-approve OneTouch Ultra Blue test strips. You say that you would like this covered.The Plan denied your request. The Plan says these is no medical reason documented you cannot use the Plan preferred meters. The Plan has also indicated they will approve a three-month transition period.The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers, as long as the MA plan ensures that enrollees have access to all medically necessary DME products or brands.We looked at the file and Medicare rules. The record does not show a medical reason you cannot use a preferred meter. The Plan has indicated they will provide a 90-day transition period. Based on this information, we decided that Medicare rules for coverage of OneTouch Ultra Blue test strips have not been met.Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay fora shingles vaccine and its administration (90750 and 90471) provided on May 17, 2019 and August 12, 2019.You asked the Plan to pay for the immunization. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the services received on these dates of service are not a covered Part B drug or service.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the immunization. Therefore, we decided that the Plan does not have to pay for a shingles vaccine and its administration (90750 and 90471) provided on May 17, 2019 and August 12, 2019.