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

We decided that the Plan does not have to pay forthe surgical services rendered on November 8, 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 procedure code 34203 is not supported.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 34203 is embolectomy or thrombectomy, with or without catheter; popliteal-tibio-peroneal artery, by leg incision.We find that CPT code 34203 is not supported in the medical record. Specifically, the operative report does not contain documentation of an embolectomy or thrombectomy. Based on this information, we decided that Medicare rules forcoverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe surgical services rendered on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electric stimulation therapy from a chiropractor.
You asked the Plan to pre-approve these services. You say that you would like the services to be covered. The Plan denied your request. The Plan says the services are not covered when performed by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. The requested services are electric stimulation and are not covered when performed by a chiropractor. Therefore, we decided that the Plan does not have to pre-approve electric stimulation therapy from a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 23, 2020.You asked the Plan to pay for the physician's services. 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 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 January 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 16,
2019.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
there is no authorization and the provider is not in-network.
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 subsequent nursing facility care provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve cardiology services. You say that your patient has seen this provider before.
The Plan denied your request. The Plan says there are multiple in-network providers available 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 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 Plan does not have to pre-approve
cardiology services 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 pay for skilled nursing services provided on December 17, 2019 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the provider isno in-network and there is no authorization on file. The Plan says that services were not plan directed and no approved nursing facility claim was received.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 skilled nursing services provided on December 17, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthotics provided on December 9, 2019.You asked the Plan to pay for the knee orthotics. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not supported as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. The documentation provided for review does not contain information in regards to the enrollee's care and treatment of osteoarthritis. The medical records do not confirm that medical necessity and Medicare coverage criteria have been met for the provided knee orthotics. Furthermore, the rules say that diagnosis codes must be billed with the most precise code that most fully explains the narrative description of the symptom or diagnosis. The file shows that the knee orthotics were billed with one or more diagnosis codes that were inappropriately coded. Medicare rules say that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific, in this case; bilateral code is available. Therefore, we decided that the Plan does not have to pay for the knee orthotics provided on December 9, 2019.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay forthe therapeutic, prophylactic, or diagnostic injection, laboratory services, radiologic examinations, CTs, simple repair of superficial wounds, closed treatment of proximal humeral, immunization administration, ED visit, Morphine Sulfate injection Tetanus, diphtheria toxoids and acellular pertussis vaccine, andECG provided on November 2, 2019.You asked the Plan to pay forthe therapeutic, prophylactic, or diagnostic injection, laboratory services, radiologic examinations, CTs, simple repair of superficial wounds, closed treatment of proximal humeral, immunization administration, ED visit, Morphine Sulfate injection Tetanus, diphtheria toxoids and acellular pertussis vaccine, and ECG. You say that this claim is not related to the hospice diagnosis.The Plan denied your request. The Plan says that Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the enrollee's applicable hospice election information. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Thus, the plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe therapeutic, prophylactic, or diagnostic injection, laboratory services, radiologic examinations, CTs, simple repair of superficial wounds, closed treatment of proximal humeral, immunization administration, ED visit, Morphine Sulfate injection Tetanus, diphtheria toxoids and acellular pertussis vaccine, and ECG provided on November 2, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for critical care (99291).
You asked the Plan to pay for critical care. You say that the documentation shows that this service was provided. The Plan denied your request. The Plan says that the time spent on this service was not documented.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is supported in the medical record. Specifically, the submitted medical records document that 36 minutes were spent on critical care on October 25, 2019. Based on this information, we decided that Medicare rules for coverage of critical care have been met. Therefore, we decided that the Plan has to pay for critical care (99291).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 6, 2020.You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this was a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora drug test provided on December 26, 2019 by an out of network (OON) provider.You asked the Plan to pay fora drug test. You say that the provider chose to send the test to our lab in effort to devise the treatment plan that is best for the patient.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that 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 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 fora drug test provided on December 26, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 3, 2020 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you were not informed that this provider was out-of-network.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services were self-referred. The Plan says that there are in-network providers available 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 an office visit provided on February 3, 2020 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from December 11, 2019 to January 6, 2020. 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's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care. The Plan also says that the enrollee enrolled in hospice on December 11, 2019.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from December 11, 2019 to January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on November 25, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency 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 services at issue in this appeal. 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 forthe medical services provided to the enrollee by an out-of-network provider on November 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection.
You asked the Plan to pre-approve these 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 Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have osteoarthritis of the right knee and a possible meniscus tear. Synvisc is recommended as a possible option for severe osteoarthritis that has not responded adequately to conservative treatments. The documentation does not support that the Synvisc would be safe and effective or medically necessary for you 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve cervical injections.
You asked the Plan to pre-approve the requested services. You say that the enrollee has more movement in her neck, and less pain with her activities of daily living. The Plan denied your request. The Plan says that the documentation do not show pain relief of 80% or greater.
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has chronic neck pain. Her MRI shows multi-level degenerative changes. She underwent bilateral C4-C5, C5-C6 and C6-C7 facet blocks. The progress note from October 23, 2019, states she had 80% pain relief. A progress note from March 25, 2020, states she had 4 months of greater than 75% pain relief. The enrollee meets the coverage criteria for a second set of diagnostic blocks. Therefore, the request is 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve cervical injections.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc One.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. He has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Synvisc One.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), and the topical application of fluoride varnish (D1206) provided on December 31, 2019.
You asked the Plan to pay for the dental services. You say that the exam was part of your preventive yearly care and should be covered. You say that you were unable to review your claims online and had to call the plan to find out why the claim was denied. You also say that you do not find this policy user friendly and will be considering other dental plan coverage in the future. The Plan denied your request. The Plan says there is an annual maximum of $1,000 for dental services that you receive in 2019. The Plan says that the annual maximum has been exhausted.
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 Annual Maximum of $1,000 has been exhausted. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), prophylaxis (D1110), the bitewing x-rays (D0274), and the topical application of fluoride varnish (D1206) provided on December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT angiogram (CTA).
You asked the Plan to pre-approve a CTA. The Plan denied your request. The Plan says this 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 CTA. Our reviewer says that the requested CTA is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the records, the enrollee has no claudication since she does not walk, and no documentation of non-healing ulcers or gangrene and ankle:brachial indices (ABI) that are normal on the right side and only minimally abnormal on the left side. ABIs are not low enough to expect claudication and certainly not low enough to cause resting limb ischemia. In this setting of no documented findings of limb ischemia, non-ambulatory state and only minimally reduced left ABI, the records do not support the medical necessity for further evaluation with an abdominal aorto CT angiogram. 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 CTA have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT angiogram (CTA).