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

We decided that the Plan has to pay forCPT codes 73110-26 billed for date of service June 6, 2020.You asked the Plan to pay forCPT codes 73110-26. You saythat procedure 73110 26/76/LT was rendered 3 times on the date of service billed, at different times. You say that the documentation provided supports the services billed.The Plan denied your request. The Plan says that the information provided does not support the frequency of the services billed within this time period.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The records provided show that there were three x-rays taken of the left wrist on the date of service billed, and that these views were compared to prior studies. The Plan did not elaborate on their denial reason, aside from stating that the documentation did not support the services billed. We find that the Plan has not substantiate their denial reason. The records do in fact match the services as they were billed.Therefore, we decided that the Plan has to pay forCPT codes 73110-26 billed for date of service June 6, 2020.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. You asked the Plan to pre-approve foot orthotics. You say that you have pain in your feet and medical conditions. The Plan denied your request. The Plan says this item is not a covered benefit. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet nerve neurolysis.You asked the Plan to pre-approvethese 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 facet nerve neurolysis is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a history of chronic low back pain. Per his provider, the patient had marked improvement in the ability to perform physical activities with the 1st diagnostic facet joint injection.  He completed one diagnostic medial branch block (MBB) on October 1, 2020 with 80 percent pain relief for five hours. He has only had one set of MBBs and does not meet the criteria for coverage of the requested neurolysis. The services are not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvefacet nerve neurolysis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on July 2, 2020 and billed under code 99205.You asked the Plan to pay forthese services. You say that this claim should be paid.The Plan denied your request. The Plan says claim billed incorrectly. The Plan says that these services have been rendered bythis providerwithin the past three years. The Plan states that theprovider needs to submit a corrected claim billed with establish patient E/M 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 claim submitted cannot be paid as billed due to a coding issue. The Plan states a corrected claim would be reviewed. Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forphysician services provided to the enrollee on July 2, 2020 and billed under code 99205.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient services provided from April 7, 2020, to April 9, 2020.You asked the Plan to pay forthe inpatient services. You say that the services were medically necessary.The Plan denied your request. The Plan says that the inpatient services were not necessary for the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services. Our reviewer says that the services were considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.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 inpatient services have been met.Therefore, we decided that the Plan has to pay forthe inpatientservices provided from April 7, 2020, to April 9, 2020.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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fo ambulance service (A0431) provided.You asked the Plan to pay for ambulance service. You say that this was billed correctly.The Plan denied your request. The Plan says this was mot billed with a required modifier.

The Plan must follow Medicare rules. Medicare rules say that in the scenario described above, in addition to the QL modifier, providers report modifier QM or QN. We looked at the file and Medicare rules.The service at issue was not billed with QM or QN.Based on this information, we decided that Medicare rules for coverage of ambulance service have not been met.Therefore, we decided that the Plan does not have to pay foambulance service (A0431) provided
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 requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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
enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the
enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an
interdisciplinary approach to rehabilitation care. The enrollee was admitted for acute blood loss anemia
associated with pseudoaneurysm of the left ICA. He had multiple surgical procedures and antibiotics. Medical
problems are stable. There are no identified problems that need inpatient medical management. There are no
complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and
occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not
a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe external ocular photography services you received on August 12, 2020.You asked the Plan to waive the copayment forthe external ocular photography services. You say that you were charged this copayment in addition to your office copayment. You say that this exam was the same as previous exams you had,and you didn't have this additional charge.The Plan denied your request. The Plan says it appropriately charged a separate copayment for this test.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 $10 copayment for diagnostic tests. You have been asked to pay a $10 copayment for the external ocular photography services. The external ocular photography services fall within the diagnostic tests benefit category. This copayment applies regardless of whether you paid a copayment in the past. 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 forthe external ocular photography services you received on August 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have waive the copayment for an eye examination provided on September 8, 2020.
You asked the Plan waive the copayment for the Medicare-covered eye examination. The Plan denied your
request. The Plan says there is a $35 copayment for each Medicare covered eye exam to diagnose and treat
diseases and conditions of the eye.
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 $35 for
vision care, Medicare-covered eye exams.
You have been asked to pay $35 for the Medicare-covered eye examination. The Medicare-covered eye
examination falls 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 waive the copayment for
an eye examination provided on September 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHydrocodone-Acetaminophen.You asked the Plan to pre-approvethe requesteddrugs. You say that the enrollee needs the medication for his chronic pain.The Plan denied your request. The Plan says the drug to be taken at home is not covered under the 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-approveHydrocodone-Acetaminophen.Benefits for the requested drugsmay be available under Medicare Part D.Contactthe 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 pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your needs can be met at a lower level of care such as long term care.
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 SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe computed tomography (CT) scan you had at an outpatient hospital facility on July 17, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that this service was prior authorized and done for diagnostic purposes.The Plan denied your request. The Plan says you were charged this copayment correctly.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 $250 copayment for advanced imaging services at an outpatient hospital facility. You have been asked to pay a $250 copayment for the CT scan. The CT scan falls within the advanced imaging services at an outpatient hospital facility benefit category. This means that you have been asked to paythe 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 forthe computed tomography (CT) scan you had at an outpatient hospital facility on July 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.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 rulesto determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hypoxemia and sepsis. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs.The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medicalrecord supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from theintensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decidedthat the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee will be able or willing to take part in 3 hours of therapy a day.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 physician reviewer found that the enrollee was admitted to the acute hospital for a stroke and heart failure. His medical problems are stable. The complexity of hisnursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There is not a reasonable expectation that hewill be able to fully participatein and benefit from the intensive rehabilitation therapy program provided in an IRF. The medical record supports a need for physical and occupational therapy,but it does not support a need for an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Prolia injection (J0897) provided on October 7, 2019.You asked the Plan to pay fora Prolia injection. You say that this was medically necessary.The Plan denied your request. The Plan says this is not documented.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 J0897 is not supported in the medical record. Specifically, while the submitted medical records note the patient would receive Prolia during the visit on the billed date of service, there is no documentation showing that Prolia was administered. Based on this information, we decided that Medicare rules for coverage of a Prolia injection have not been met.Therefore, we decided that the Plan does not have to pay fora Proliainjection (J0897) provided on October 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a SNF. You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.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 admission toa SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with chronic kidney disease, encephalopathy and hyperkalemia. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain with effect. She was alert with confusion.  She tolerated dialysis. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrolleewas at a maximal assist level with functional mobility. The enrollee 
required varying assist with activities of daily living.There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee doesnot require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBENLYSTA (J0490).You asked the Plan to pre-approveBENLYSTA. You say that the drug is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully reviewthe case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve BENLYSTA. Our reviewer says that BENLYSTA is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the BENLYSTA is safe and effective for the patient. It's use in the setting of lupus nephritis is not recommended.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BENLYSTA have not been met.Therefore, we decided that the Plan does not have to pre-approveBENLYSTA (J0490).