Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.You asked the Plan to pre-approve the injection. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not been seen by a specialist or attempted a complete trial of conservative therapies.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee has not been seen by a specialist or attempted a complete trial of conservative therapies.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 injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hand x-ray rendered on September 17, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 73130 was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that anatomical modifiers are required for component codes.We looked at the file and Medicare rules. The provider billed procedure code 73130 (radiologic examination, hand; minimum of 3 views) without a required anatomical modifier. Based on this information, we decided that Medicarerules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe hand x-ray rendered on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Relion syringes.You asked the Plan to pre-approve Relion syringes. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of your Part D plan.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 Relion syringes.Benefits for Relion syringe smay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 30, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee received no skilled nursing services during this time frame.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from November 1, 2019 to November 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta 32mg injections for the enrollee. You asked the Plan to pre-approve the injections. You say that you have tried several cortisone shots prior to this injection, and they would leave you in pain. The Plan denied your request. The Plan says Zilretta injections are not approved by the Food and Drug Administration (FDA) for repeat use and can only be used once per knee per lifetime. 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 the injections. Our reviewer says that the requested injections are not medically reasonable or necessary. Our physician reviewer found per the FDA approved prescribing information, Zilretta is indicated for the management of knee pain due to osteoarthritis and is not intended for repeat administration and can only be used once per knee per lifetime. The authorization for repeat administration of Zilretta for either knee cannot be provided. Based on a review of the information submitted, you have already received a Zilretta injection for each knee on September 11, 2019. The documentation does not support that the service at issue is medically reasonable and 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta 32mg injections for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positive airway pressure device and supplies for the enrollee.You asked the Plan to pre-approve the device. You say that this is medically necessary.The Plan denied your request. The Plan says there is a lack of medical necessity and appropriateness of the requested items.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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found CPAP was prescribed, but the enrollee is no longer using it. More recently, the enrollee was treated for coronary artery disease. Re-initiation of CPAP has been advised, and a new device was prescribed. However, a repeat PSG is needed, because it has been 13 years since the original PSG, and the enrollee's weight and health status have changed. This could be a split-night study, with PAP titration. Therefore,the PAP device is considered not medically necessary, at least until a repeat PSG is 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 the device have not been met.Therefore, we decided that the Plan does not have to pre-approve a positive airway pressure device and supplies for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 4, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on November 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter supplies rendered on December 24, 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. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 31 for a skilled nursing facility (SNF). Payment for these services is included in the SNF facility payment.Therefore, we decided that the Plan does not have to pay for the catheter supplies rendered on December 24, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the head.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records do not note the frequency or severity of the reported headaches. There is no report of recent trauma and no complaint of associated neurological findings. The physical exam notes no neurological findings. The requested CT scan is not reasonable or medically necessary based on the submitted records. 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 a computed tomography (CT) scan of the head
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886) provided on October 8, 2019.You asked the Plan to pay for needle electromyography. You say that the records clearly indicate this code was performed.The Plan denied your request. The Plan says this code is 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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure).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 95886 is not supported in the submitted medical records. Our physician reviewer found the medical records provided do not include a detailed report to validate that a Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 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 needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for needle electromyography (95886) provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided on January 16,
2020.
You asked the Plan to waive the copayment for vision services. You say that you received a routine eye exam
and should not owe the $45 copayment. The Plan denied your request. The Plan says the claims were processed
correctly and you are being charged the correct 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 $45
copayment for eye exams to diagnose and treat diseases and conditions of the eyes.
The medical records shows that you received diagnostic vision services on January 16, 2020. Therefore, you
are responsible to pay the $45 copayment.
You have been asked to pay a $45 copayment for vision services. Vision services fall within the vision care
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 vision services provided on
January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve outpatient office visit. You say that you would like approval to see this provider. The Plan denied your request. The Plan says there are in-network providers available.
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 care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
You asked the Plan to pre-approve the injection. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint radiofrequency neurotomy is covered for the above indications. 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 injection. Our reviewer says that the requested lumbar/sacral facet joint radiofrequency neurolysis is not medically reasonable and necessary. Our physician reviewer found that the documentation indicates that the enrollee received a lumbar medial branch block on February 6, 2020, and reported 80% pain relief. He also received a transforaminal epidural steroid injection (TESI) on January 2, 2020, and reported 80% pain relief. His provider has recommended lumbar/sacral facet joint radiofrequency neurolysis. According to LCD (L34993), the enrollee does not meet the indications for lumbar RF neurotomy. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar/sacral facet joint radiofrequency neurolysis.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that on the date of service you passed out at a restaurant and someone called 911. The EMS responders came and after evaluating you, they advised you that you should go to the hospital. You say that you did not know that you had to ride with the ambulance for the services to be covered and instead you had your daughter take you to the hospital. You asked the Plan to consider providing coverage. 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 19, 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 for the ambulance services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from November 7, 2019 to November 26, 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 claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that value codes are required for home health claims. We looked at the file and Medicare rules. The claims were not billed with the required value code. 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 home health services rendered from November 7, 2019 to November 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services (CPT 99053) provided to the enrollee on November 21, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the charge for this service is included in another procedure code.
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 99053 is "Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service." We asked our coding 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 the services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT code 99053 has a Payment Status of "B" Bundled Code, which states - Payment for covered services are always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. We looked at this coder'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 pay for hospital services (CPT 99053) provided to the enrollee on November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the special gingival flap procedure (D4241 x2), the special application of biological material for tissue regeneration (D4265), and the medicaments (D9630) provided on December 2, 2019.
You asked the Plan to pay for the special gingival flap procedure (D4241 x2), the special application of biological material for tissue regeneration (D4265), and the medicaments (D9630). You say that the services were medically necessary. The Plan denied your request. The Plan says the services are not covered 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. Though the Plan offers a dental benefit in excess of Medicare coverage, the special gingival flap procedure (D4241 x2), the special application of biological material for tissue regeneration (D4265), and the medicaments (D9630) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the special gingival flap procedure (D4241 x2), the special application of biological material for tissue regeneration (D4265), and the medicaments (D9630) provided on December 2, 2019.
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 you need further treatment. The Plan denied your request. The Plan says the services are 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 records show that you were admitted to the hospital with a skin infection (necrotizing fasciitis). You were admitted to a skilled nursing facility (SNF) on March 31, 2020. The records show that you needed assistance with bed mobility, transfers, dressing, and toileting. The records do not support that you require the intensity of services in an IRF. Specifically, you do not need fifteen hours per week of rehabilitative services and regular physician evaluation. You may benefit from further therapy but do not require an intensive therapy program 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 inpatient rehabilitation facility (IRF) admission and services.