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

We decided that the Plan does not have to pay for hyalgan supartz injections (J7321) provided on April 17,
2019 through June 17, 2019.
You asked the Plan to pay for the injections. You say that authorization is not required for this service. The
Plan denied your request. The Plan says Per Medicare guidelines, J7321 has not met the associated diagnosis
code relationship criteria.
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 J7321 is not supported in the record. Specifically, per Local Coverage Article: Billing
and Coding: Hyaluronan Acid Therapies for Osteoarthritis of the Knee (A55036), the diagnosis code submitted
does not support medical necessity. 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 pay for hyalgan supartz
injections (J7321) provided on April 17, 2019 through June 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on July 31, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered to the enrollee on July 31, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on June 13, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered on June 13, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean echocardiogram to be provided by an out of network (OON) provider.You asked the Planto pre-approvethe OON echocardiogram. You say that this imaging is necessary to evaluate the enrollee's condition.The Plandenied your request. The Plansaysthis standard imaging can be provided by a network provider. There is no medical rationale for this to be provided OON.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 Plandoes not haveto pre-approvean echocardiogram 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 a lumbar/sacral facet joint block.
You asked the Plan to pre-approve a lumbar/sacral facet joint block. You say that the requested lumbar/sacral facet joint block is medically necessary. The Plan denied your request. The Plan says the requested lumbar/sacral facet joint block does not meet criteria.
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 lumbar/sacral facet joint block. Our reviewer says that the requested lumbar/sacral facet joint block does not meet criteria. Our physician reviewer found the enrollee has spinal stenosis, lumbar radiculopathy and neurogenic claudication. The request is for diagnostic facet blocks. The enrollee has received an epidural steroid injection with a good response. The enrollee has had physical therapy and medication trials. The LCD criteria are not met because there is clear evidence of on-going multiple pain generators. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a lumbar/sacral facet joint block have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on October 25, 2019 to October 28, 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 the claim was not billed with the required FIPS code.The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with the FIPS code of the place where the services were rendered.We looked at the file and Medicare rules. The claims were not billed with the required FIPS 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 forthe services rendered on October 25, 2019 to October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit on October 15, 2019.You asked the Plan to waive the copayment forthe emergency room visit. You say that you would like the cost-sharing waived because you believed you were inpatient.The Plan denied your request. The Plan says that you were charged 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 Emergency care. You have been asked to pay a $50 copayment for the emergency room visit. The emergency room visit falls within the Emergency 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 forthe emergency room visit on October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic radiology services provided on April 26, 2019.
You asked the Plan to pay for the diagnostic radiology services. The Plan denied your request. The Plan says
you must receive care from in-network providers with the exception of emergency or urgent care, or if the care
cannot be provided with an in-network provider, which requires prior authorization from the plan
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
service 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 diagnostic radiology services provided on April 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76872 and 76942) provided on August 27, 2019.You asked the Plan to pay for the ultrasound. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician.The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Specifically, the technical component of these services is paid to the hospital. Therefore, we decided that the Plan does not have to pay for an ultrasound (76872 and 76942) provided on August 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 25, 2019.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.

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 physician's services provided on March 25, 2019.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH 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 admission to a LTACH is not medically necessary. Our physician reviewer found in the case of this enrollee, following her fall and unresponsiveness, subdural hemorrhage was diagnosed and treated in the current acute care hospital. Mechanical ventilation and surgery was needed. Current notes show that the enrollee is still dependent on mechanical ventilation and is unresponsive. Recent notes showed that the enrollee tolerated 4-6 hours of CPAP suggesting a possible weaning potential. Additional attempts to wean would be indicated to further determine if there is a high enough likelihood of requiring more than 25 days of long-term acute care. There are no required services requested for treatment at the proposed LTACH which aren't already being provided and covered at the current acute care facility. Further weaning at the current facility is appropriate. Therefore without sufficient recent support for this request for transfer to LTACH, it will be considered not medically necessary 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on August 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that these services were medically necessary. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services.
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 has network providers available who can provide the items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for lab work provided on August 5, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on February 18, 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 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on February 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a lab test provided on August 12, 2019 by an out of network (OON) provider.
You asked the Plan to pay for a lab test. You say that these services were considered medically necessary. The Plan denied your request. The Plan says the referring providers were out-of-network. The Plan says that no prior authorization was obtained for these services.
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 has network providers available who can provide the items/services at issue in this appeal. 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. Therefore, we decided that the Plan does not have to pay for a lab test provided on August 12, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve epidural steroid injection (62323)
You asked the Plan to pre-approve epidural steroid injection. You say that this service is medically necessary
because you have lower back pain from a pinched nerve. The Plan denied your request. The Plan says that there
are no notes indicating that you have tried Physical Therapy.
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 the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve epidural steroid injection. Our reviewer
says that the requested items/services are considered medically reasonable and necessary in this case. Our
physician reviewer found you have tried and failed conservative therapy, including Physical Therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of epidural steroid injection have been met. Therefore, we decided that the Plan
has to pre-approve epidural steroid injection (62323)
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and applythe 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 while the enrollee would likely benefit from continued physical therapy (PT) and occupational therapy (OT), the documentation does not support the need for daily therapy on an inpatient basis in an SNF. The enrollee can now use ten stairs with little to no help and can walk 400 feet with a little help. The enrollee's records did not show why she cannot continue her rehabilitation where she currently is at and that she will need daily nursing care after she finishes rehabilitation.We looked at this physician's review, the file, and Medicare rules. Basedon 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-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01936) provided on August 20, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says minor pain procedures under most routine circumstances do not require anesthesia careother than local anesthesia.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 anesthesia services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found minor pain procedures under most routine circumstances do not require anesthesia care other than local anesthesia. There was no specific clinical rationale for the requested epidural steroid injection with anesthesia.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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01936) provided on August 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Syringe.
You asked the Plan to pre-approve Repatha. You say that Repatha is medically necessary. The Plan denied
your request. The Plan says coverage for Repatha is not available under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Repatha Syringe.
Benefits for Repatha 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing services provided from June 20, 2019 to July 19, 2019.You asked the Plan to pay forthe skilled nursing services. You say that theservices which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate setting other than a SNF.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 forthe skilled nursing services provided from June 20, 2019 to July 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH services are medically necessary.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of the LTACH services.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 current acute care needs can be received at the current facility. There are no proposed services at the LTACH which are not already covered and available at the current facility. Therefore, this request for LTACH will be considered not medically necessary 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-approvelong term acute care hospital (LTACH) services.