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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF. You say that you had a stroke and need continued physical assistance
for basic self-care needs and for walking. You say that you have limited movement and use of your right arm
and hand. You say that you also have weakness in your right leg and poor balance. You say that this puts you at
high risk for falls. You say that you live alone and do not have support available. The Plan denied your request.
The Plan says the enrollee does not need daily skilled services to be provided only on an inpatient basis in a
SNF. The Plan says that the enrollee's needs may be met at a lower level of care.
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. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled
nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not
shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition.
The enrollee's care needs, as a practical matter, can be provided at a lower 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 SNF have not been met. Therefore, we decided that the Plan does not have to
pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 you do not require skilled nursing and/or
skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation
services at a lower level of care. Although further rehabilitation services would be appropriate to improve
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a
skilled nursing facility.
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 skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
You asked the Plan to provide coverage for additional routine transportation trips. You say that you need additional transportation rides for dental and physical therapy appointments. The Plan denied your request. The Plan says you have exhausted the maximum benefit of 48 one-way trips per year.
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. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips (A0120).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76700) provided on May 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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 76700 has a bundled relationship with code 93976 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 the services (76700) provided on May 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by the referring provider on
January 12, 2021, to January 15, 2021.
You asked the Plan to pay for inpatient hospital care. You say that the enrollee had a history of chest pain for
two days. The Plan denied your request. The Plan says the enrollee did not have any complications including
cardiac dysfunction.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with secondary diagnosis code, I50.31 - acute diastolic
(congestive) heart failure. 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 inpatient hospital
care. Our reviewer says that the elements of the coverage criteria have not been satisfied and the requested
service cannot be recommended. Our physician reviewer found the record does not indicate the presence of
cardiac dysfunction nor does the documentation indicate that there was an affect upon the enrollee's care in
terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of
hospital stay; or increased nursing care and/or monitoring.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital care provided by the referring provider on January 12, 2021, to January 15, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ostomy pouch (A5063), provided on May 4, 2021, and May 28, 2021.
You asked the Plan to waive the copayment for the ostomy pouch. You say that the items should be covered. The Plan denied your request. The Plan says the cost share 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 $50 copayment for prosthetic devices and related supplies. You have been asked to pay $49.40 out of a $50 copayment for the ostomy pouch. This item falls within the prosthetic devices and related 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 the ostomy pouch (A5063), provided on May 4, 2021, and May 28, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 you do not require skilled nursing services
with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively
provide medically necessary and reasonable treatment in a SNF. Your functional level does not require skilled
therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and
effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing
or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical
matter you do not require the necessary services on 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on April 14, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 file shows that the provider submitted a claim for procedure code 99203 (office visit). Therefore, we decided that the Plan does not have to pay for the office visit rendered on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression devices provided on March 23, 2021.
You asked the Plan to pay for intermittent limb compression devices. You say that the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression devices provided on March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Prometheus FIBROSpect NASH test provided to you on 
February 25, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is an experimental 
test. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that this test is medically necessary for distinguishing hepatic cirrhosis from non-cirrhosis in persons 
with hepatitis C and other chronic liver diseases (e.g., hereditary hemochromatosis, NAFLD and NASH). 
Performance of this test more than twice per year is considered not medically necessary.

Performance of this test within 6 months following a liver biopsy or transient elastography is considered not 
medically necessary. This test is considered experimental and investigational for all other indications (e.g., 
diagnosis and/or monitoring of primary biliary cholangitis). 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the Prometheus FIBROSpect NASH test provided to you on February 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (70450) provided to the enrollee on May 30, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed in this case.
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 70450 is "Computed tomography, head or brain; without contrast material." We find that CPT code 70450 is not supported in the medical record. Specifically, this code cannot be paid separately from CPT 70496 without the appropriate modifier. 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 imaging services (70450) provided to the enrollee on May 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Euflexxa injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a trial and failure of any of the step one drugs.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed a Step 1 viscosupplemental treatment such as, Hyalgan, Hymovis, and Synvisc. Step therapy, as outlined by the plan, requires that one of these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Euflexxa is not approved as step 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Euflexxa injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia complicated by emergency conditions coded
99140 provided on May 8, 2021.

You asked the Plan to pay for the anesthesia complicated by emergency conditions. 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
separately payable.

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 99140 is anesthesia complicated by emergency
conditions (specify) (List separately in addition to code for primary anesthesia procedure).

We find that CPT code 99140 is not supported in the medical record. Specifically, this code has a status
indicator of "B" which means this code is a bundled code. Payment for these services are included in other
services not specified. Based on this information, we decided that Medicare rules for coverage of the anesthesia
complicated by emergency conditions have not been met. Therefore, we decided that the Plan does not have to
pay for the anesthesia complicated by emergency conditions coded 99140 provided on May 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 16, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the visit with an orthopedic surgeon and Kenalog injection you received on June 15, 2021.
You asked the Plan to waive the cost sharing for the orthopedic surgery visit and the Kenalog injection. You say that you were not aware there would be any copayment. The Plan denied your request. The Plan says you were charged this cost sharing 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 $25 copayment for visits with a specialist and 20% coinsurance for Medicare Part B drugs. You have been asked to pay a $25 copayment for the orthopedic surgery visit and 20% coinsurance for the Kenalog injection. The orthopedic surgery visit falls within the visits with a specialist benefit category and the Kenalog injection falls in the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amounts 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 cost sharing for the visit with an orthopedic surgeon and Kenalog injection you received on June 15, 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 enrollee currently meets IRF admission criteria.
The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 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. While the
record supports a need for physical and/or occupational therapy, there is no documented need for an intensive
rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully
participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF.
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 pay for the services (75625, 75710) provided on April 13, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot 
be verified. 
 
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 75625 is "Aortography, abdominal, by serialography, 
radiological supervision and interpretation". 
 
We asked our coder 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 services. Our reviewer says that the use of code 75625 is 
not supported by the records provided. Our reviewer found that the procedural report does not document an 
aortography was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. 
 
Additionally, we have confirmed that code 75710 has a bundled relationship with code 37226 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 the services (75625, 
75710) provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the out-of-network physician services provided on March 10, 2021.
You asked the Plan to pay for the office visit (99214) and psychotherapy (90833). You say that the provider charged you for the unpaid claim. The Plan denied your request. The Plan says there is a billing error and a corrected claim must be submitted by the provider.
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 claim has a mismatched National Provider Identifier (NPI) and cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of the office visit (99214) and psychotherapy (90833) have not been met. Therefore, we decided that the Plan does not have to pay for the out-of-network physician services provided on March 10, 2021.