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

We decided that the Plan does not have to pre-approve an MRI scan of the abdomen.
You asked the Plan to pre-approve an MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested MRI is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI. Our reviewer says that the documentation does not support that the requested MRI scan is medically reasonable or necessary. Our physician reviewer found you have a distant history of being stabbed in abdomen and has has non-specific symptoms. Abdominal pain is not an indication for MRI of the abdomen. There is nothing in the history that would suggest that an MRI would be appropriate in this situation. Therefore, you do not meet criteria for the requested 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 an MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the abdomen.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the seat lift equipment purchased on July 3, 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 provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the seat lift equipment purchased on July 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on May 30, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the claim was filed after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after thedate of service.The record shows that a claim for the services was not filed until June 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe services provided on May 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear services coded 85060 provided on June 22, 2020.
You asked the Plan to pay for the blood smear services. You say that you would like the plan to reconsider their denial. 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, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by physician with written report, for the service described. We find that CPT code 85060 is not supported in the medical record. Specifically, this code was billed with a place of service of 22, on campus-outpatient hospital. The PC/TC indicator for this code is 8. This value identifies the only payment made for the professional component of the code is for hospital inpatient. Based on this information, we decided that Medicare rules for coverage of the blood smear services have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear services coded 85060 provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forglasses provided on October 8, 2019.You asked the Plan to pay forthe glasses. You say that you would like reconsideration because you paid the full price for these eyeglasses in March 2020.The Plan denied your request. The Plan says you exhausted your 2019 benefit for eyeglasses in February 2019.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers theseservices once per calendar year. We looked at the file and the Plan's rules. [Insert determination explanation]. Based on this information, we decided that the Plan's rules for coverage of the glasses have not been met. Specifically, the record indicates that you exhausted your 2019 benefit for eyeglasses on February 12, 2019. The second pair of eyeglasses provided on October 8, 2019 is not covered.Therefore, we decided that the Plan does not have to pay forglasses provided on October 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided by Sarasota County Board of County Commissioners Ambulance on December 17, 2019.You asked the Plan to pay forthe ambulance services. You say that you were treated in place by the medics.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on December 17, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided by Sarasota County Board of County Commissioners Ambulance on December 17, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe opthamologyservices (67107RT, 80047, 85014, C9399) provided on May 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forOON opthamology services. You say that you were told this was authorized.The Plan denied your request. The Plan says this was not authorized.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, outof 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 forthe opthamology services (67107RT, 80047, 85014, C9399) provided on May 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foranesthesia services provided on February 18, 2020.You asked the Plan to pay formonitored anesthesia care (MAC). You say that the Plan should pay this claim.The Plan denied your request. The Plan says clinical documentation did not clearly establish an indication for monitored anesthesia care.The Plan must follow Medicare rules. MediWe looked at the file and Medicare rules. There is no information substantiating the use of MAC for this procedure over local anesthesia or minimal conscious sedation. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met.Therefore, wedecided that the Plan does not have to pay foranesthesia services provided on February 18, 2020.care rules say that providers must produce medical records to support the services billed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordialysis services (90999, A4657, J1756) provided December 1, 2019 to December 7, 2019.You asked the Plan to pay forthe dialysis services. You say that the services were medically necessary.The Plan denied your request. The Plan says required values were not included on the claim.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT codes 90999, A4657, J1756 are not supportedin the medical record. Specifically, the claim did not include the required G0491 coding with a required revenue code noting the modality of the dialysis. Based on this information, we decided that Medicare rules for coverage of the dialysis services havenot been met.Therefore, we decided that the Plan does not have to pay fordialysis services (90999, A4657, J1756) provided December 1, 2019 to December 7, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services provided from March 18,
2020, to May 27, 2020.
You asked the Plan to pay for home infusion therapy services. You say that the Plan should pay this claim. The
Plan denied your request. The Plan says this procedure code is not valid for Medicare purposes.
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 S9328 is home infusion therapy, implanted pump pain
management infusion; administrative services, professional pharmacy services, care coordination, and all
necessary supplies and equipment (drugs and nursing visits coded separately), per diem.
We find that CPT code S9328 is not a valid code for Medicare purposes. S codes are unique temporary codes
established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare
uses another code for reporting of, and payment for, these services. Based on this information, we decided that
Medicare rules for coverage of home infusion therapy management have not been met.. Therefore, we decided
that the Plan does not have to pay for home infusion therapy services provided from March 18, 2020, to May
27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on June 10, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that coverage for all CV risk assessment panels, except the basic lipid panel, is denied for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The requested risk assessment panel is non-covered per L36523. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on June 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation feature and enhanced steering
performance unit.
You asked the Plan to pre-approve the power seat elevation feature and enhanced steering performance unit.
You say that you would like reconsideration because these accessories are medically necessary. The Plan
denied your request. The Plan says this equipment is not primarily medical in nature.
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 power seat elevation feature and enhanced steering
performance unit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for aquatic therapy provided on October 9, 2019.
You asked the Plan to pay for aquatic therapy. You say that the enrollee was pre-approved, so you provided 10 visits. You say that the claims should be processed for payment. The Plan denied your request. The Plan says the techniques used could have been applied using land based physical therapy.
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 pay for aquatic therapy. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the enrollee did not participate in manual therapy and only in gentle exercise and stretches. Our reviewer says that the techniques used could have been applied using land based physical therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of aquatic therapy have not been met. Therefore, we decided that the Plan does not have to pay for aquatic therapy provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthetic infusion (64449) provided on December 10, 2019.
You asked the Plan to pay for anesthetic infusion. You say that there is not a code for the procedure performed.
The Plan denied your request. The Plan says this code is not appropriate.
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 64449 is injection(s), anesthetic agent(s) and/or steroid;
lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement).
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 anesthetic infusion. Our reviewer says that
the use of this code is not supported by the records. Our physician reviewer found the procedure report does not
include enough documentation to support a continuous infusion was performed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of anesthetic infusion have not been met. Therefore, we decided that the Plan does
not have to pay for anesthetic infusion (64449) provided on December 10, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approveinpatient hospital services.You asked the Plan to pre-approveinpatient services. You say that with dissections,there is swelling which can affect the airway.The Plan denied your request. The Plan says that the enrollee does not require inpatient services.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.Inpatient hospital services were requested for the enrollee's approved facial surgery. 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 services. Our physician reviewer found that the enrollee is having a complex procedure where facial and hypoglossal nerves will beanastomosed. There is a lotof neck dissection and potential for swelling and airway compromise. The extensive surgery involves the possibility of airway compromise. Therefore, the requestedadmission is indicated and medically reasonable.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 services have been met.Therefore, we decided that the Plan has to pre-approveinpatient hospital services.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on March 5, 2020.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says screening tests are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The testing 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 forthe lab services provided on March 5, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patch.
You asked the Plan to pre-approve Fentanyl patch (J3490). You say that you want the enrollee treated with this drug. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Fentanyl patch.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvesix (6) additional home health/hospice aide (HHA) services (CPT Code G0156 X6) and twenty-two (22) additional skilled nursing services (G0299 X22).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 physician reviewer found based on the documentation provided, the health plan's denial should be upheld. You are receiving home health nursing services and, therefore, may qualify for HHA services. However, the documentation does not adequately show what HHA services are required and how these services would medically benefit you. As such, the number/frequency of HHA visits requested is not shown to be medically necessary or reasonable.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-approvesix (6) additional home health/hospice aide (HHA) services (CPT Code G0156 X6) and twenty-two (22) additional skilled nursing services (G0299 X22).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic screening testing provided on December 3, 2019.

You asked the Plan to pay for genetic tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these tests were ordered by telemedicine which is a Medicare prohibited action and the tests were performed for screening purposes.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

The tests at issue in this appeal, genetic tests, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for genetic screening testing provided on December 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea back injection (64493).You asked the Plan to pre-approvea back injection. 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 Facet Joint Interventions are considered medically reasonable and necessary when specific criteria is 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 a back injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the request does not meet the coverage criteria due to prior surgery at the planned levels of injection as well as probable alternate pain generators. Therefore, the request is deemed not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a back injection have not been met.Therefore, we decided that the Plan does not have to pre-approvea back injection (64493).