Persius/hicric huggingface dataset:
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 care is medically necessary. The Plan denied
your request. The Plan says coverage criteria has not been met.
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 enrollee needs PT and OT but does not require IRF level of therapies. The
enrollee's therapy needs can be met at a lower 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam (92004) provided January 30, 2020. You asked the Plan to pay for the eye exam. You say that the eye exam is a covered benefit. The Plan denied your request. The Plan says at the time the service was provided, your benefit for eye exams was already exhausted. 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 one eye exam a year, with an $18 copayment. We looked at the file and the Plan's rules. A claim for an eye exam provided on February 28, 2020 was already processed and paid at the time the claim for the January 30, 2020 eye exam was filed. The plan only provides coverage for one eye exam a year. Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for an eye exam (92004) provided January 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Crysvita (J0845).
You asked the Plan to pre-approve Crysvita. You say that Crysvita is medically necessary. The Plan denied your request. The Plan says the records provided do not support the need for this medication.
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 Crysvita. Our reviewer says that this drug is not medically necessary. Our physician reviewer found the enrollee is noted to have common variable immunodeficiency. A request was made for Crysvita, which is indicated for the treatment of x-linked hypophosphatemia. As there is no evidence that the enrollee has x-linked hypophosphatemia, the requested drug is not indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Crysvita have not been met. Therefore, we decided that the Plan does not have to pre-approve Crysvita (J0845).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe inpatient initial hospital evaluation and management (EM) services provided on December 15,2019, reported with the inpatient place of service (POS) code 21.You asked the Planto pay forthe inpatient EM services. You say that this was billed with the correct POS code and should be paid due to medical necessity.The Plandenied your request. The Plansaysthe enrollee was not an inpatient on this date of service. Payment cannot be made for inpatient EM services rendered to an outpatient.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 99223 is Initialhospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.We find that CPT code 99223 is not supported in the medical record. Specifically, evidence was presented showing that this was an outpatient hospitalization. As such, payment can only be made for outpatient EM codes. Based on this information, we decided that Medicare rules for coverage of the inpatient EM services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe inpatient initial hospital evaluation and management (EM) services provided on December 15, 2019, reported with the inpatient place of service (POS) code 21.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by an in-network provider on February 12, 2020.
You asked the Plan to waive the copayment for specialist services. You say that you never had a copayment before for this. The Plan denied your request. The Plan says the correct copayment 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 copayment for physician/practitioner services/specialist. You have been asked to pay $8.98 which is less than your copayment amount of $20 for specialist services. Since specialist services were provided, the correct copayment has been applied. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by an in-network provider on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecervical epidural steroid injections.You asked the Plan to pre-approvethe steroid injections. You say that you would like reconsideration because physical therapy is too painful.The Plan denied your request. The Plan says you havenot tried and failed physical therapy.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 steroid injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physicianreviewer found there is no documentation of an adequate trial of evidenced-based, conservative treatment, such as 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 the steroid injections have not been met.Therefore, we decided that the Plan does not have to pre-approvecervical epidural steroid injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe upper partial denture-cast metal framework (D5213).You asked the Plan to pre-approvetheupper partial denture-cast metal framework (D5213). The Plan denied your request. The Plan says only one procedure per 60 months is allowed.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the Plan also has a maximum benefit of one complete upper denture (D5110), immediate denture (D5130), upper partial denture-resin base (D5211)or upper partial denture-cast metal framework (D5213)every 60 months. The Plan approved an upper partial denture-resin base (D5211)on June 24, 2020, which exhausted thebenefit.Therefore, we decided that the Plan does not have to pre-approvethe upper partial denture-cast metal framework (D5213).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an X-ray of the hip (73502) performed February 2, 2020.You asked the Plan to pay for the X-ray. You say that the services were medically necessary.The Plan denied your request. The Plan says the record does not support 2 units being billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 73502 is not supported in the medical record. Specifically, the record shows only one unit of CPT 73502 being provided. A second claim for the same CPT code is not supported. Based on this information, we decided that Medicare rules for coverage of the X-ray have not been met.Therefore, we decided that the Plan does not have to pay for an X-ray of the hip (73502) performed February 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve1 physical therapy, 1 social worker visit, and 3 nursing visits.You asked the Plan to pre-approve1 physical therapy, 1 social worker visit, and 3 nursing visits. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicarerules. 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 1 physical therapy, 1 social worker visit, and 3 nursing visits. Our reviewer says that the documentation does not support that the requested home health services are medically reasonable or necessary. Our physician reviewer found there is no documentation of complex wounds, there are no parental medications or a feeding tube. The documentation does not support that the enrollee has had a recent exacerbation of chronic medical problems. the documentation doesn't support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 1 physical therapy, 1 social worker visit, and 3 nursing visits have not been met.Therefore, we decided that the Plan does not haveto pre-approve1 physical therapy, 1 social worker visit, and 3 nursing visits.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for needle electromyography (51785) provided on March 12, 2020.
You asked the Plan to pay for needle electromyography. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that the documentation submitted did not
support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of
code 51785 is Needle electromyography studies (EMG) of anal or urethral sphincter, any technique.
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 needle electromyography. Our reviewer says
that CPT code 51785 meets criteria for billing and reimbursement consideration. Our physician reviewer found
the case file contains a Technical Report with the following modalities: Lower EMG which included the Anal
SPh. S2-S4. It is noted that the EMG traces were quiet at baseline and closing, and that no neurotonic
discharges were noted. The documentation supports CPT code 51785.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of needle electromyography have been met. Therefore, we decided that the Plan
has to pay for needle electromyography (51785) provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet-rich plasma injection.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered by Original Medicare to treat chronic non-healing diabetic, pressure, and/or venous wounds.
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 injection is not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure at this time. You are not in a clinical trial. Therefore, the request is considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet-rich plasma injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF care. You say that the records provided support the
need for continued care in the SNF. The Plan denied your request. The Plan says the criteria for coverage have
not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above 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 the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received
oral medications, had stable vital signs, and a fair appetite. The enrollee received physical therapy and
occupational therapy in the SNF. By the dates in question, the enrollee was at a dependent to maximal assist
level with functional mobility and activities of daily living. There are no identifiable skilled nursing service
needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness
or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care and daily skilled rehab therapy.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray provided on March 2, 2020.You asked the Plan to pay for the first intraoral periapical x-ray and additional intraoral periapical x-ray. You say that you were overcharged for these services without your permission.The Plan denied your request. The Plan says these services are not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only x-rays that are covered under your plan are bitewing x-rays and full mouth or panoramic x-rays.Therefore, we decided that the Plan does not have to pay forthe first intraoral periapical x-ray and additional intraoral periapical x-ray provided on March 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 8, 2019.You asked the Plan to pay for the drug testing. 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.We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation did not include any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met.Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient behavioral health facility for
the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says there is a 190-day lifetime limit for inpatient services in a psychiatric hospital.
The Plan must follow Medicare rules. Medicare rules say that there is a 190 day limit for inpatient psychiatric
services.
The enrollee has exhausted their inpatient psychiatric services. Based on this information, we decided that
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve admission to an inpatient behavioral health facility for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two applications of desensitizing medicaments provided on February 24, 2020.You asked the Plan to pay for the applications of desensitizing medicaments. You say that this provider was on the list of the Plan's network providers.The Plan denied your request. The Plan says this service is not covered.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason,the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, 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 two applications of desensitizing medicaments provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).You asked the Plan to pre-approve radiofrequency ablation (RFA). You say that the requested RFA is medically necessary.The Plan denied your request. The Plan says the enrolleedoes not meet criteria for the requested RFA.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 radiofrequency ablation (RFA). Our reviewer says that the enrollee does not meet criteria for the requested RFA. Our physician reviewer found the review indicates that the enrollee is with a history of low back pain due to lumbar spondylosis without myelopathy or radiculopathy. The enrollee had a radiofrequency ablation (RFA) of lumbar spine in 2017 which was highly successful at that time. He has also had an RFA in December 2018 at L3-L4, L4-L5, and L5-S1 which did not provide significant pain relief. The enrollee also underwent a spinal cord stimulator trial which was successful but he refused permanent implantation. He presently has low back pain without numbness, tingling, or radiation of pain. The enrollee's provider recommended a repeat RFA at L3-L4, L4-L5, and L5-S1. In this case, the documentation does not indicate that the last procedure improved the enrollee's pain and ability to perform his daily activities by at least 50% for 6 months or more. The review has determined that the enrollee does not have a covered indication for the requested RFA.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation (RFA) have not been met.Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).