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

We decided that the Plan does not have to pre-approve arthrodesis, SI joint, percutaneous or minimally
invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and
placement of transfixing device (CPT code 27279), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee has had bilateral diagnostic SI joint
injections with put anesthetic agent with 70% relief (which is due to SI joint disease and not hip disease). You
state the enrollee is not a candidate for hip replacement due to their morbid obesity. You state this procedure
can give relief for their pain and get back their quality of life. The Plan denied your request. The Plan says the
documentation does not include imaging reports (computed tomography (CT) scan or X-ray) of the hip joints
or SI joint to evaluate for alternative or contributing diagnoses (total hip replacement complication or SI Joint
destructive process). The Plan states there are adjacent contributing problems (lumbar synovial cyst).
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 service. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with
image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279) is
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 service have not been met. Therefore, we decided that the Plan does not
have to pre-approve arthrodesis, SI joint, percutaneous or minimally invasive (indirect visualization), with
image guidance, includes obtaining bone graft when performed, and placement of transfixing device (CPT code
27279), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that this request is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says the rules for SNF care 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 in the Medicare rules section 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee is an 88-year-old female who was
admitted to an acute care hospital on August 23, 2021, for weakness and sepsis after a fall. In this case, there
are no documented daily skilled nursing needs. At the enrollee's current level of function, she does not require
daily skilled therapies in an inpatient setting. The enrollee's rehab needs can be met with home health services
and intermittent 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (72170) provided on January 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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, we have confirmed that code 72170 has a bundled relationship with code 73502 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (72170) provided on January 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 26, 2021.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.

We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 23, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, 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 for the laboratory services rendered on December 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on April 13, 2021.
You asked the Plan to pay for the dental service. You say that you usually go to the dentist in April and October. You say that the dentist was closed until June in 2020 due to coronavirus. You also say that you feel you should not have to pay for the x-rays because the office was closed, and it messed up your schedule. The Plan denied your request. The Plan says bitewing x-rays once in a 12-month period. The Plan says that the frequency limit has been exceeded.
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 and bitewing x-rays are listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that you received on June 9, 2020, less than 12 months ago. Therefore, we decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on April 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on March 23, 2021.
You asked the Plan to pay for the fixed partial denture sectioning. You say that you were advised by a plan representative that D9230 and D7210 would be covered. You say that you are not sure why the services were denied. You also say that you provider called the plan and was told the services would be covered too. The Plan denied your request. The Plan says the fixed partial denture sectioning is not listed as a covered service.
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 fixed partial denture sectioning is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
fixed partial denture sectioning (D9120) provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the podiatry visit you had on March 25, 2021.
You asked the Plan to waive the copayment for the podiatry visit. You say that you do not believe you should have to pay a copayment when all you want is to have your toenails cut. You say this should be considered preventive maintenance. 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 $45 copayment for podiatry services. Medical records from this podiatry visit show that you did not just receive toenail cutting. In addition, you were evaluated and treated for athlete's foot as well as a hematoma on your right big toe. These are services above and beyond preventive foot care. You have been asked to pay a $45 copayment for the podiatry visit. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the podiatry visit you had on March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the lesion removals provided on November 19, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the lesion removals. You say that the services are medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent Therefore, we decided that the Plan does not have to pay for the lesion removals provided on November 19, 2020 by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve otolaryngology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that delaying consultation will cause your condition to worsen. 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve otolaryngology services to be provided by an out-of-network (OON) provider.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you do not have rehabilitation needs from multiple therapy disciplines,
would not benefit from an intensive rehabilitation program, do not have complex medical management needs,
and do not require supervision by a rehabilitation physician.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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.
The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for weakness, hydrocephalus, and
urinary tract infection. Your medical problems are stable. There are no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy,
and an intensive rehabilitation therapy program. While the documentation does support a need for physical
and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation
program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition
does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80048, 83036, 85027, 85610)
provided on March 16, 2021, by an OON provider.
You asked the Plan to pay for laboratory services. You say that you saw this provider due to an emergent
situation and would like this visit covered. The Plan denied your request. The Plan says services were provided
by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The records show that you moved
from Arizona to Minnesota. The records also show that you had an annual office visit to establish care with a
new provider. The Plan had network providers available who could have provided the items/services at issue in
this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not
show that the services at issue were urgent or emergent. We found no exception that would require the Plan to
pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services
(36415, 80048, 83036, 85027, 85610) provided on March 16, 2021, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neuromonitoring (95822, 95927, 95938)
provided on January 20, 2021.
You asked the Plan to pay for intraoperative neuromonitoring. You say that this was billed with the correct
place of service because you bring your own equipment. The Plan denied your request. The Plan says this was
not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if a mobile unit is serving an entity for which
another place of service (POS) code already exists, providers should use the POS code for that entity.
We looked at the file and Medicare rules. These services were billed with Mobile Unit POS code 15, but the
records show that they were provided in service of an entity for which a POS already exists. Based on this
information, we decided that Medicare rules for coverage of intraoperative neuromonitoring have not been met.
Therefore, we decided that the Plan does not have to pay for intraoperative neuromonitoring (95822, 95927,
95938) provided on January 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nubeqa.
You asked the Plan to pre-approve Nubeqa. You say that the enrollee is castration resistant. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Nubeqa.
Benefits for Nubeqa may 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered from February 3, 2021 to March 17, 2021.
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 procedure code 99072 is not covered.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered from February 3, 2021 to March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve inpatient hospital services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
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.
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 hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee. The enrollee is undergoing a planned total knee arthroplasty. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is not listed on the Centers for Medicare & Medicaid Services Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it has been more than 2 years since the enrollee's last procedure.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. We looked at the file and Medicare rules. The records show that the enrollee's last radiofrequency ablation procedure was in 2018. If there is an extended period of time since the last RFA, diagnostic procedure must be repeated. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services where you were treated, but not transported, on February 24, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you didn't call the ambulance and you didn't ask for help, so you should not have to pay the copayment. 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 $50 copayment for ambulance services where you are treated but not transported. You have been asked to pay a $50 copayment for the ambulance services. This copayment applies regardless of why you received the services. 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 ambulance services where you were treated, but not transported, on February 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on April 19, 2021.
You asked the Plan to pay for the dental service. You say that you were in the hospital as a result of your tooth pain. You say that you were advised by a plan representative that you would not be charged for the service. You also say that you feel this charge should be written off or waived. The Plan denied your request. The Plan says 1 periapical x-ray is covered per calendar year. The Plan also says that the frequency limit has been exceeded.
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 and periapical x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a periapical x-ray that you received on April 14, 2021. Therefore, we decided that the Plan does not have to pay for the periapical x-ray (D0220) provided on April 19, 2021.