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

 
We decided that the Plan does not have to pay for the laboratory services coded 88341, 88365, 88333, 88305, 
88173, 88177, and 88172 provided on June 6, 2019. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as 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. 
Codes 88341 and 88177 were denied due to being billed as an add-on code without a base code. If an 
appropriate primary code is not allowed or found, then the applicable add-on code will also be denied. 
Codes 88173, 88305, and 880365 are duplicate claim clines because the documentation shows that these codes 
have been previously processed and paid. We have confirmed that code 88172 and 88333 have a bundled 
relationship with code with 88173 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 laboratory services coded 88341, 88365, 88333, 88305, 88173, 88177, and 
88172 provided on June 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a rituximab injection (J9312) provided on February 27, 2020.
You asked the Plan to waive the coinsurance for a rituximab injection. You say that you need this twice a year and cannot afford it. The Plan denied your request. The Plan says this processed 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 20% coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. You have been asked to pay a $1,888.22 coinsurance for a rituximab injection ($9,441.10 allowed amount x 20% = $1,888.22). 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 coinsurance for a rituximab injection (J9312) provided on February 27, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on February 13, 
2020. 
 
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 ordering provider did not justify or show medical necessary or rationale for this testing done. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found there was no indication for most of the items tested on the panel. There was not sufficient documentation 
provided to suggest that typical urine testing not be performed. This modality of testing was not indicated 
based on the records provided. 
 
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 pay for laboratory services provided to the enrollee on February 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for synvisc injections (J7325) provided 
October 17, 2019. 
 
You asked the Plan to waive the coinsurance for the injections. You say that the coinsurance should be waived. 
The Plan denied your request. The Plan says the correct coinsurance was applied for the services at issue. 
 
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% 
coinsurance for Part B Drugs.  
 
You have been asked to pay a 20% coinsurance for the injections. The injections fall within the Part B Drugs 
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 coinsurance for synvisc injections (J7325) 
provided October 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the emergency treatment of dental pain and endodontic 
therapy provided on April 21, 2020. 
 
You asked the Plan to pay more for the emergency treatment of dental pain and endodontic therapy. You say 
that the Plan only paid $800, but you have been told that your dental allowance for 2020 is $2,000. The Plan 
denied your request. The Plan says the Plan has paid the annual limit allowed by your dental plan for the 2020 
benefit year. 
 
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 offers an $800 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit while processing this claim on April 21, 2020 and your annual maximum benefit has been 
exhausted. Therefore, we decided that the Plan does not have to pay more for the emergency treatment of 
dental pain and endodontic therapy provided on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the arthrocentesis and the Part B injection provided on February 10, 2020.
You asked the Plan to waive the copayment for the arthrocentesis and the Part B injection. You say that you were never informed you would have a copayment for the injection. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $30 copayment for a specialty physician and 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a $30 copayment for the arthrocentesis. You have also been asked to pay $118.91 which is 20% of the allowed amount for the Part B injection. The allowed amount is $594.56. ($594.56 x 20% = $118.91). The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs" 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 the arthrocentesis and the Part B injection provided on February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not medically necessary. Our physician reviewer found the enrollee's
ongoing care needs include respiratory support with oxygen supplementation, surveillance laboratory studies,
tube feeding, and therapy services. The documentation does not support that the enrollee in this case requires
services at the LTACH that are not available at the acute care hospital where he is currently receiving care.
There are no required medical services identified that are available at the LTACH, that are not available at the
current health care setting being offered by the health plan. Consequently, the requested LTACH services are
not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided a participating ambulatory facility on February 20, 2020.
You asked the Plan to waive the copayment for a diagnostic colonoscopy. You say that you do not agree with this copayment. 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 $235 copayment for outpatient surgery/in-network/surgery services/ambulatory surgical center. You have been asked to pay a $235 copayment for a diagnostic colonoscopy. Since a diagnostic colonoscopy was provided, the correct copayment has been applied. A diagnostic colonoscopy falls within the outpatient surgery/in-network/surgery services/ambulatory surgical center 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 a diagnostic colonoscopy provided by a participating ambulatory facility on February 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bilateral sacroiliac joint block. 
 
You asked the Plan to pre-approve a bilateral sacroiliac joint block. You say that the requested bilateral 
sacroiliac joint block is medically necessary. The Plan denied your request. The Plan says the requested 
bilateral sacroiliac joint block is not medically necessary. 
 
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 bilateral sacroiliac joint block. Our 
reviewer says that the requested bilateral sacroiliac joint block is not medically necessary. Our physician 
reviewer found the enrollee is diagnosed with back pain. There are no imaging studies that show SI joint 
dysfunction. Medical necessity for SI joint injection has not been shown. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bilateral sacroiliac joint block have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a bilateral sacroiliac joint block.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation does not support that the enrollee in this case requires services at 
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no 
required medical services identified that are available at the LTACH, that are not available at the current health 
care setting being offered by the health plan. Consequently, the requested LTACH services are not medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Superion Interspinous Spacer System (Vertiflex). 
 
You asked the Plan to pre-approve a Superion Interspinous Spacer System (Vertiflex). You say that the 
requested Superion Interspinous Spacer System (Vertiflex) is medically necessary. The Plan denied your 
request. The Plan says the requested Superion Interspinous Spacer System (Vertiflex) is not medically 
necessary. 
 
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 a Superion Interspinous Spacer System 
(Vertiflex). Our reviewer says that the requested Superion Interspinous Spacer System (Vertiflex) is not 
medically necessary. Our physician reviewer found the enrollee is diagnosed with neurogenic claudication 
caused by spinal stenosis. The spacer remains experimental for use in spinal surgery. More research is needed 
to show safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Superion Interspinous Spacer System (Vertiflex) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Superion Interspinous Spacer System 
(Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical fusion.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your
request. The Plan says based upon a review of the records provided and the medical literature, the requested
service does not appear to be medically reasonable or medically necessary.
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 surgery. Our reviewer says that the
requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no instability. There is no documentation of a neurological deficit. There is no correlation
between the documented physical exam, and the imaging studies. Surgery is not needed at this time.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve cervical fusion.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve sacroiliac joint injections (27096). 
 
You asked the Plan to pre-approve the injections. You say that you would like reconsideration because this 
service is medically necessary. The Plan denied your request. The Plan says the documentation does not show 
radiographic findings or provocative testing for biomechanical pain. 
 
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 injections. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical picture that is suggestive of sacroiliac injury and/or disease. There are no 
radiographic findings or provocative testing for a sacroiliac joint source of pain. In addition there is no 
documentation the member has failed at least 4-6 weeks of aggressive conservative 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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve sacroiliac joint injections (27096).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 21, 
2019. 
 
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says 
non-emergent, non-urgent services with out-of-network providers require 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 Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for a domiciliary, rest home visit provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient surgical services rendered 
from January 2, 2020 to March 27, 2020. 
 
You asked the Plan to waive the copayments for these services. You say that you disagree with the charges. 
The Plan denied your request. The Plan says the copayments were applied 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 $325 
copayment for each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility visit.  
 
Review of the file shows that you received outpatient surgical services from January 2, 2020 to March 27, 
2020. You have been asked to pay a $325 copayment per date of service for these services. These services fall 
within the each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility visit 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 copayments for the outpatient surgical services rendered from 
January 2, 2020 to March 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the enrollee cannot tolerate three hours of therapy per day, at least five days a week.
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 do not indicate that there are significant, or complex medical/nursing
issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication
management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of
therapy will allow for measurable gains to be attained within a reasonable, and predicted period. An IRF
intensity is not warranted.
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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital services (CPT 29445) provided to the 
enrollee on April 21, 2020. 
 
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 services that are considered column II procedures to another service are not eligible for 
reimbursement. 
 
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 29445 is "Application of rigid total contact leg cast." 
 
We find that CPT code 29445 is not supported in the medical record. Specifically, this code is a column II 
procedure to the column I procedure - CPT 97597. 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 
outpatient hospital services (CPT 29445) provided to the enrollee on April 21, 2020.