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

We decided that the Plan does not have to pre-approve MRI, abdomen; without contrast material(s) (CPT code 74181), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your request. The Plan says their records show that the same study (or a similar study) has already been approved for the enrollee. The Plan states a separate approval letter has been sent to the enrollee for the approved study. The Plan states the approved study may give the enrollee's doctor the information needed to treat the enrollee's problem (condition). The Plan states further imaging can only be approved when additional tests are needed to direct the enrollee's care. The Plan states they asked the enrollee's doctor to tell the Plan if this is a different study than the one approved but did not hear back; therefore, without that answer, the Plan cannot approve more tests.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our physician reviewer found the record indicates that the enrollee has abdominal pain. The record indicates that a similar study has been already been approved. The record does not indicate why the requested service is medically necessary and reasonable, as defined by Medicare rules, for the enrollee's condition. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, abdomen; without contrast material(s) (CPT code 74181), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is at risk for another heart attack and stroke and needs twenty-four (24) hour attention. The Plan denied your request. The Plan says the stay is not medically necessary.
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 documentation does not support the need for therapy program consisting of at least three (3) hours of therapy per day at least five (5) days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. However, the enrollee will benefit from skilled nursing facility (SNF) level of therapies as notes indicated that the enrollee never received any inpatient coordinated rehabilitation. Additionally, to avoid future readmission to the hospital with aspiration related pneumonia more frequent speech therapy in an inpatient SNF rehabilitation setting is very justifiable. IRF admission is not medically necessary based on lack of medical complexity, and poor functional status. The enrollee's therapy needs can be addressed at a lower intensity and alternate setting such as in an SNF with daily therapies. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit rendered on May 11, 2021.
You asked the Plan to waive the copayment for these services. You say that the services were an annual
wellness visit and should have no copayment. The Plan denied your request. The Plan says the copayment was
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10
copayment for each primary care doctor office visit for Medicare-covered services.
Review of the file shows that you had a primary care physician office visit on May 11, 2021. You were seen for
an annual wellness visit but also received services related to hypertension and hyperlipidemia. You have been
asked to pay a $10 copayment for these services. These services fall within the primary care doctor office visit
for Medicare-covered services 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 office
visit rendered on May 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307, G0483) provided September 15, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 80307, & G0483 is not supported in the medical record. Specifically, the place of service listed on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (80307, G0483) provided September 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rehabilitation services provided August 14, 2020 to September 1, 2020.
You asked the Plan to pay for the rehabilitation services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 the rehabilitation services are not supported in the medical record. Specifically, the dates of service billed were August 14, 2020 to September 1, 2020. The number of absence days submitted is greater than the number of days for the billed stay. The Plan has noted that a corrected claim is required. Based on this information, we decided that Medicare rules for coverage of the rehabilitation services have not been met.
Therefore, we decided that the Plan does not have to pay for the rehabilitation services provided August 14, 2020 to September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet blocks.
You asked the Plan to pre-approve facet blocks. 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 follows Medicare rules. Medicare rules say that a second diagnostic facet procedure is considered medically reasonable and necessary to confirm validity of the initial diagnostic facet procedure when administered at the same level. 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 facet blocks. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that you do not meet the coverage criteria for the requested procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve facet blocks.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided from February 8, 2021, through February 17, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says continuation of SNF services provided from February 8, 2021, through February 17, 2021 are 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 in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee is a 66-year-old male with Coronavirus (COVID-19) pneumonia, atrial fibrillation and respiratory failure. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had routine foley catheter care. His appetite was good. He had uncomplicated wound care to his coccyx. Regarding rehabilitation services, the enrollee did not receive nor require skilled therapy for the dates in question. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation SNF services provided from February 8, 2021, through February 17, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medication assisted treatment program, methadone, (G2067) provided on February 27, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for Medication assisted treatment program. You say that you did not know that for an out of network provider, an authorization is required before the claims are submitted. You ask that for a one time basis, that the initial authorization request and initial claims are processed. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 medication assisted treatment program, methadone, (G2067) provided on February 27, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT (CPT code 77525), for the enrollee.

You asked the Plan to pre-approve the PBRT. You say that the services are necessary. The Plan denied your request. The Plan says there is no evidence that proton beam irradiation therapy is the most appropriate treatment option for the enrollee based on risk stratification.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medically necessary criteria have not been 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 the PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve the PBRT (CPT code 77525), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation provided on April 22, 2021, for a hospital outpatient.
You asked the Plan to pay for the blood smear interpretation. You say that this was provided and billed in the appropriate place of service. The Plan denied your request. The Plan says this code is not payable in the hospital outpatient setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code 85060 has a Pro/Tech flag of "8" in the Physician Fee Schedule. This flag indicates that the service is only payable when provided for a hospital inpatient. No payment is recognized for CPT codes 88141, 85060 or HCPCS code P3001-26 furnished to hospital outpatients or non-hospital patients. The physician interpretation is paid through the clinical laboratory fee schedule payment for the clinical laboratory test. Based on this
information, we decided that Medicare rules for coverage of the blood smear interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear interpretation provided on April 22, 2021, for a hospital outpatient.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88305) provided on May 18, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers 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 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 had network providers available who could have provided the services at issue in this appeal. 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 lab services (88305) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional twenty-nine (29) routine transportation miles, for the enrollee.

You asked the Plan to pre-approve additional routine transportation miles. You say that the enrollee is in the neurology clinic and has a diagnosis of essential tremor and Parkinson's Disease. You state the enrollee is completely and permanently unable to work in any job or occupation. The Plan denied your request. The Plan says the enrollee exhausted their benefit limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Review of the file shows that you are requesting an additional 29 miles for a total of 79 miles. The enrollee's benefit only allows 50 miles and the enrollee has exceeded their benefit limit. Therefore, we decided that the Plan does not have to pre-approve additional twenty-nine (29) routine transportation miles, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on April 26, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

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 had network providers available who could have provided 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 the rest home visit provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (C1787, C1767, 61886, 93005) provided on August 19, 2020.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the out-of-network services were not emergent or pre-authorized.
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 had network providers available who could have provided the services at issue in this appeal. 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 outpatient services (C1787, C1767, 61886, 93005) provided on August 19, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99307) provided on December 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. We looked at the file and Medicare rules. In this case, the billed E/M services were provided on the same date
of service, by a provider in the same group practice and of the same specialty, as a separate E/M service (99309). These second E/M service is not separately payable. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99307) provided on December 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.

You asked the Plan to pre-approve a portable ventilator. 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 follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered for specific conditions. 

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 portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found a home ventilator is not medically necessary. Bilevel positive airway pressure (BiPAP) at night may be beneficial for you. But there is no documentation that BiPAP has been tried and failed in the home setting. Certain BiPAP devices can provide the average volume assured pressure support (AVAPS) mode of support, and Medicare does not cover a ventilator when used as BiPAP. 

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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.