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

We decided that the Plan does not have to pre-approve medial branch block facet injections.

You asked the Plan to pre-approve Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level (64490), Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) (64491), Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (64492). You say that the enrollee had much better function with a lot less pain with previous medial branch blocks. The Plan denied your request. The Plan says the local coverage determination criteria state only two levels, unilateral or bilateral are allowed per session.

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 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint cervical or thoracic; single level (64490), Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) (64491), Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (64492). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request exceeds utilization criteria. The first set of MBbs should be interpreted as NEGATIVE and should NOT be repeated. Other pain generators should be sought. The request is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injections 64490, 64491, 64492 have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch block facet injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the wrist provided on February 11, 2021.

You asked the Plan to waive the copayment for an x-ray of the wrist. You say that your provider could not find the x-rays and must have misfiled them. You also say that you should not have to pay for lost x-rays. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 copayment for outpatient diagnostic tests and therapeutic services and supplies including x-rays.

You have been asked to pay a $20 copayment for an x-ray of the wrist. The EOC confirms that $20 is the required copayment for this service. The records show that there was only one (1) x-ray of the wrist done on the date of service during a postoperative visit. An x-ray of the wrist falls within the outpatient diagnostic tests and therapeutic services and 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 copayment for an x-ray of the wrist (73110) provided on February 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT of the head or brain (70450) provided on January 5, 2021.

You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration because these services were performed separately and billed with the appropriate modifiers. The Plan denied your request. The Plan says CPT code 70450 is a column II code to CPT code 70496 which was billed on the same date of service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the CT of the head or brain has a bundled relationship with code 70496 and cannot be paid as billed. Modifier 77 is not an appropriate modifier to bypass the NCCI edit. 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 CT of the head or brain (70450) provided on January 5, 2021.
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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found there is no documented need for an intensive rehabilitation program and you do not have any complex nursing or rehabilitation needs.

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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a permanent bladder stimulator.

You asked the Plan to pre-approve placement of a permanent bladder stimulator. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that patients with stress incontinence, urinary obstruction, and specific neurologic diseases which are associated with secondary manifestations of the above three indications are excluded from coverage. 

We looked at the file and Medicare rules. In this case, the patient has been diagnosed with the neurological disease Multiple Sclerosis. Therefore, the enrollee has a specific neurologic disease excluded from coverage. Based on this information, we decided that Medicare rules for coverage of placement of a permanent bladder stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a permanent bladder stimulator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a podiatry office visit and debridement of
nails provided on January 19, 2021.

You asked the Plan to waive the copayment for a podiatry office visit and debridement of nails. You say that
you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being
charged is correct.

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 $40
copayment for podiatry services.

You have been asked to pay a $40 copayment for a podiatry office visit and debridement of nails. The EOC confirms that $40 is the required copayment for this service. The records show that the $40 copayment was split between the office visit and debridement of nails ($25 + $15 = $40). 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 podiatry office visit (99213) and debridement of nails (11721) provided on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for nuclear medicine, an X-ray and wound
debridement provided from October 7, 2020, to February 10, 2021.

You asked the Plan to waive the copayments for nuclear medicine, an X-ray and wound debridement. You say
that you were not informed that there would be such a high copayment and disagree with the charges. The Plan
denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the
correct 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $100 copayment for advanced imaging services, a $10 copayment for X-rays and a $200 copayment
for surgery services for outpatient hospital services for outpatient hospital services. 

The enrollee received nuclear medicine, an X-ray and wound debridement provided from October 7, 2020, to February 10, 2021. Therefore, the enrollee is responsible to pay their share of the cost-sharing charges. Please see the chart below.

Date of Service
Service
Amount Enrollee Owes

10/7/2020
Nuclear Medicine
$20

10/12/2020
X-ray
$10

10/19/2020
Wound Debridement
$169.74

10/26/2020
Wound Debridement
$169.74

11/2/2020
Wound Debridement
$200

11/6/2020
Wound Debridement
$200

11/23/2020
Wound Debridement
$200

12/2/2020
Wound Debridement
$200

12/14/2020
Wound Debridement
$200

12/28/2020
Wound Debridement
$169.74

1/13/2021
Wound Debridement
$200

1/27/2021
Wound Debridement
$200

2/19/2021
Wound Debridement
$200

The total amount the enrollee owes is: $2,139.22. 

The enrollee has been asked to pay the total copayment amount of $2,139.22 for nuclear medicine, an X-ray and wound debridement. Nuclear medicine, an X-ray and wound debridement fall within the outpatient hospital services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for nuclear medicine, an X-ray and wound debridement provided from October 7, 2020, to February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) provided on February 4, 2021.

You asked the Plan to pay for the office visit. You say that you would like reconsideration because this service was billed correctly. The Plan denied your request. The Plan says the submitted claim was not billed with an appropriate POS code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We find that CPT code 99214 is not supported in the record. Specifically, when billing for telehealth services during the Public Health Emergency, bill with the POS code which represents where the service would have been had it been in person. This claim was billed with POS 12 indicating the member's home. This is not an appropriate POS code for the service billed. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on February 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740 x3).

You asked the Plan to pre-approve crowns. You say that you want the Plan to pay for the services. The Plan
denied your request. The Plan says the coverage criteria have not been met for the services at issue to be
covered.

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. The Plan covers crowns when
the criteria listed above are met.

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 crowns. Our reviewer says that the
coverage criteria have not been met. Our physician reviewer found tooth #8 has a crown in the submitted
radiographic image. Tooth #9 does not have destruction of four or more surfaces and at least 50% of the incisal
edge. Tooth #10 is not completely imaged.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of crowns have not been met. Specifically, coverage criteria have not been met.
Therefore, we decided that the Plan does not have to pre-approve crowns (D2740 x3).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for mobile x-ray services (R0070, Q0092, 73030) provided
December 26, 2020.

You asked the Plan to pay for the mobile x-ray services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the services are not eligible for separate payment.

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 R0070, Q0092, & 73030 are not supported in the medical record. Specifically, the
record shows the enrollee was an inpatient at the time services were rendered. These services are not eligible
for separate payment when the enrollee is an inpatient, per CMS Claims Processing Manual Chapter 13,
Section 90.

Based on this information, we decided that Medicare rules for coverage of the mobile x-ray services have not been met. Therefore, we decided that the Plan does not have to pay for mobile x-ray services (R0070, Q0092, 73030) provided December 26, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye injection and does not have to waive the coinsurance for a Medicare Part B drug provided on January 21, 2021.

You asked the Plan to waive the copayment for an eye injection and to waive the coinsurance for a Medicare Part B drug. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $50 copayment for specialist services. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B drugs. 

You received an eye injection on January 21, 2021. Therefore, you are responsible to pay $10, which is less than the $50 copayment.

You received a Medicare Part B drug on January 21, 2021. The total allowed amount is $1,902.10 and 20% of that is $380.42. 

The total amount you owe is: $390.42. 

You have been asked to pay the total amount of $390.42 for an eye injection and a Medicare Part B drug. An eye injection falls within the physician/practitioner services, including doctor's office visits benefit category. A Medicare Part B drug 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 an eye injection and does not have to waive the coinsurance for a Medicare Part B drug provided on January 21, 2021.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID 19 pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs.

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of 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 pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 enrollee does not require services at the LTACH that are not available at the acute
care hospital where he is currently receiving 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 the LTACH services have not been met. Specifically, medically necessary
services are being provided at the enrollee's current level of care. This means admission into a LTACH is not
medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve LTACH
services.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee was admitted for coronary artery disease requiring angioplasty, renal failure requiring hemodialysis, sepsis, bowel necrosis requiring bowel resection, and atrial fibrillation. Medical conditions are stable. There are no complex nursing or rehabilitation needs. 

The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MRI's to be provided by an out-of-network provider.

You asked the Plan to pre-approve the MRI's. You say that there is no difference between getting the MRI in different states. You say that you got sick and now need an MRI. The Plan denied your request. The Plan says in-network providers were available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 the MRI's to be provided by an out-of-network provider.