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

We decided that the Plan does not have to pay for the angiography services coded 75774 and the selective catheter placement services coded 36248 provided on March 15, 2020.
You asked the Plan to pay for the angiography services and the selective catheter placement 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. We find that CPT codes 75774 and 36248 are not supported in the medical record. Specifically, code 75774 was not billed with one of the following procedure codes: 75600, 75605,75625, 75630, 75635, 36221, 36222, 36223, 36224, 36225, 36226, 75710, 36227, 36223, 36224, 75705, 75710, 75716, 75726, 75731, 75733, 75736, 75741, 75743, 75746, 75756, 36901, 36902, 36903, 36904, 36905, or 36906. Since the primary procedure code of 75774 was not allowed, the add on code of 36248 is not allowed as well. Based on this information, we decided that Medicare rules for coverage of the angiography services and the selective catheter placement services have not been met. Therefore, we decided that the Plan does not have to pay for the angiography services coded 75774 and the selective catheter placement services coded 36248 provided on March 15, 2020.
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 the care is not complex enough and does not show it would cause 
excessive physical hardship for the patient to receive needed care on an outpatient basis or skilled nursing 
facility. 
 
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. You 
are medically stable with no evidence of need for supervision by acute physical medicine and rehab physician 
or acute rehab nursing care. You may benefit from further physical therapy (PT) and occupational therapy (OT) 
but do not require an intensive therapy program. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided from October 22, 2019 to October 26, 2019.
You asked the Plan to waive the copayment for the inpatient hospital care. The Plan denied your request. The Plan says that you are responsible for a $350 copayment.
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 $350 copayment for each Medicare-covered hospital stay. You have been asked to pay a $350 copayment for the inpatient hospital care. The inpatient hospital care falls within the Medicare-covered hospital stay 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 inpatient hospital care provided from October 22, 2019 to October 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient hospital supplies (C1732) provided November 1, 2019.
You asked the Plan to waive the coinsurance for the outpatient hospital supplies. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 20% coinsurance for medical supplies. You have been asked to pay a 20% coinsurance for the outpatient hospital supplies. The outpatient hospital supplies fall within the medical supplies 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 outpatient hospital supplies (C1732) provided November 1, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says the requested services have been found to be not medically necessary. 
 
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 the admission. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are 
identified. The enrollee may benefit from skilled therapy; however, the documentation does not support that 
skilled services on a daily basis in an SNF are medically reasonable and necessary. 
 
 
 
 
 
 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) 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 admission 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 to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee is with metastatic renal 
cell cancer, a fall and altered mental status and was admitted to the hospital. From a nursing perspective, the 
enrollee received oral medications and insulin. The enrollee had stable vital signs. He had poor oral intake and 
Hospice was being considered. Regarding rehabilitation services, the enrollee received physical therapy and 
occupational therapy in the acute hospital. The enrollee was at a moderate assist of 2 level with functional 
mobility including gait to 2 feet with a rolling walker.  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 does not 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-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lumbar epidural injection. 
 
You asked the Plan to pre-approve a lumbar epidural injection. You say that the requested lumbar epidural 
injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet 
criteria for the requested lumbar epidural injection. 
 
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 epidural injection. Our 
reviewer says that the enrollee does not meet criteria for the requested lumbar epidural injection.  
 
Our physician reviewer found there is no clear diagnosis of radiculopathy. There is no documentation of 
correlation between exam findings and imaging showing exact nerve root compression that is symptomatic on 
exam. Criteria for injections not met. 
 
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 epidural injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a lumbar epidural injection.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided by a participating 
provider on March 11, 2020. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you did not realize the medicine and 
the surgery would be billed separately. You say that this should be billed the same. The Plan denied your 
request. The Plan says the correct coinsurance 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 20% 
coinsurance for Medicare Part B prescription drugs/in-network/in-network.  
 
You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed 
amount is $2,888.53. The total amount you are being asked to pay is $577.71 ($2,888.53 x 20% = $577.71). 
The correct coinsurance has been applied to the injections that were provided. An injection falls within the 
Medicare Part B prescription drugs/in-network/in-network 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 an injection provided by a participating provider on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided on February 26, 2020. 
 
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, dialysis while 
temporarily out of the plan's service area 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 
physician's services. 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 February 26, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg with multiple components.
You asked the Plan to pre-approve leg prosthetics. You say that you are appealing. The Plan denied your
request. The Plan says the denial of authorization for these items is correct.
The Plan follows Medicare rules. Medicare covers replacement prosthetic items for the specific circumstances
listed 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 leg prosthetics. Our reviewer says that
the enrollee does not meet the Medicare criteria for the requested prosthetics. Our physician reviewer found
you currently has a prosthesis that he uses on a daily basis at work, which was approved in 2017. The requested
prosthesis is to be used for swimming and ambulating on uneven terrain. The documentation does not support
that there has been a change in the physiological condition of yourself, nor is there documentation of an
irreparable change in the condition of the existing prosthesis or its parts.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of leg prosthetics have not been met. Therefore, we decided that the Plan does not
have to pre-approve a prosthetic leg with multiple components.
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 a 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 with a history of hip joint pain with movement that causes abdominal pain. The
SI joint injections are not medically needed. There is no clear correlation with all of the physical exam findings
and the imaging shows only mild sclerosis. Criteria for SI injection are not met. There is also no SI joint
instability or lesion.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on March 13, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intracardiac electrophysiologic mapping (93613) and intracardiac echocardiography (93662) provided on November 19, 2019.
You asked the Plan to pay for the electrophysiologic mapping and echocardiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the primary procedure code 93656 was denied, therefore these add-on codes are also denied.
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 codes the electrophysiologic mapping and echocardiography have a bundled relationship with code 93656 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 intracardiac electrophysiologic mapping (93613) and intracardiac echocardiography (93662) provided on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing services provided from February 15, 2019 
to March 12, 2019. 
 
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required 
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee 
had no skilled therapy or skilled nursing service needs. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed above are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the skilled nursing services. Our reviewer 
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the 
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment 
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the 
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily 
skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the 
Plan does not have to pay for the skilled nursing services provided from February 15, 2019 to March 12, 2019.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan does have to partially pre-approve the PET scan only limited to the heart.
You asked the Plan to pre-approve the PET scan. You say that this test is appropriate to reach a proper diagnosis and to institute appropriate therapy for the patient. The Plan denied your request. The Plan says the PET scan is not necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our physician reviewer found the PET/CT of the heart is indicated, however our doctor does not understand the added benefit of extending the study through the thighs. If the patient has sarcoid involving the heart, further manifestation or spread of this systemic condition would not alter therapy. Our doctor states there should be approval of PET/CT of heart but no indication for further imaging to involve through the thigh. The testing is approved limiting to the heart. 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 PET scan have been partially met. Therefore, we decided that the Plan does have to partially pre-approve the PET scan only limited to the heart.
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 14, 2019 
and billed under codes G0483.  
 
You asked the Plan to pay for code G0483. You say that this claim should be paid. The Plan denied your 
request. The Plan says while code 80307 was paid, the records provided do not support the billing of code 
G0483. 
 
The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of 
testing. The physicians order and the medical records must specifically show how this testing will be used to 
treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for 
screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we 
decided that the Plan does not have to pay for genetic testing provided to the enrollee on August 14, 2019 and 
billed under codes G0483.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 25, 2019. 
 
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says 
the Plan requires utilization of network providers when possible and available, and requires authorization for 
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency 
situation, has been documented. 
 
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 subsequent nursing facility care provided on March 25, 2019.