Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lipid panel (80061) provided on July 26, 2021.
You asked the Plan to pay for the lipid panel. You say that you would like reconsideration because this testing
was medically necessary due to a needed adjustment in medication. The Plan denied your request. The Plan
says that the records to not support a medically necessary indication for the frequency of the lipid testing.
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. Specifically, the Plan indicates that medical records were reviewed to establish
that medical necessity criteria have not been met. The Plan has failed to forward the medical records that were
reviewed. Additionally, the record indicates that these services were ordered and rendered by a contracted
provider. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the lipid panel
(80061) provided on July 26, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation.
You asked the Plan to pre-approve ambulance transportation. You say that there is overwhelming evidence to
support the need for ambulance transportation. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because the enrollee is not bed-confined and is able to ambulance with
assistance.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ambulance transportation. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested ambulance transportation. Our
physician reviewer found the record does not support that other means of transportation (such as stretcher van,
wheelchair van) are contraindicated for the enrollee. The documentation does not support that the enrollee
needs the expertise, services, and lifesaving or life-sustaining equipment that only a fully equipped ambulance
can provide for safe transport. Ambulance transportation is not 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 ambulance transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve ambulance transportation
Appeal type: Surgery
Decision: Partially Favorable

asked the Plan to pre-approve the varicose vein ablation treatment. You say that the procedure is
medically necessary. The Plan says that coverage criteria has not been met.
We decided that the Plan has to pre-approve the left side ablation procedure.
Our physician reviewed the case file and Medicare rules, and determined that the left side meets criteria and is
medically reasonable and necessary.
We also decided that the Plan does not have to pre-approve the right side ablation procedure.
Our physician found that the right side does not meet criteria because there is a subacute thrombus. The Right
side is not medically reasonable or necessary.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on July 18, 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 71045 (chest x-ray) and 36573 (insertion of peripherally inserted central venous catheter).
Code 71045 is a column II code with a modifier indicator of 1 when billed with column I code 36573. Code 71045 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 chest x-ray rendered on July 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ear-nose-throat (ENT) surgical services provided on November 6, 2020, billed with code 30130 and a second unit of code 31276.
You asked the Plan to pay for the surgical services as billed. You say that the claim was correctly billed and should be paid. The Plan denied your request. The Plan says 30130 is not supported in the record. In addition, the second unit of 31276 is not payable due to the MUE.
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 30130 is Excision inferior turbinate, partial or complete, any method. 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 surgical services as billed. Our reviewer says that the records do not support the billing of code 30130. Our reviewer found the operative report does not include documentation of an excision inferior turbinate. Therefore, this code cannot be verified. We looked at this coder's review, the file, and Medicare rules. We also found that the MUE value of code 31276 is one, with an MAI of 2. Two units of this code were billed, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the ear-nose-throat (ENT) surgical services provided on November 6, 2020, billed with code 30130 and a second unit of code 31276
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the extracapsular cataract removal provided on July 13, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the extracapsular cataract removal. 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 extracapsular cataract removal provided on July 13, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and the ophthalmoscopy provided on January 15, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the eye exam and the ophthalmoscopy. You say that the provider is in-network, and the services were medically necessary. The Plan denied your request. The Plan says 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows the provider is out-of-network. Therefore, we decided that the Plan does not have to pay for the eye exam and the ophthalmoscopy provided on January 15, 2021, by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and bone replacement graft provided (D7953) on May 26, 2021.
You asked the Plan to pay for the guided tissue regeneration (D4267) and bone replacement graft provided (D7953). You say that you were in a car accident and your implants and natural sound tooth were crushed. You say that the services should be paid through medical. The Plan denied your request. The Plan says the services are not covered benefits.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4267) and bone replacement graft provided (D7953) on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary visit provided on April 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary visit. You say that this service does not require prior authorization, and the service was medically necessary. The Plan denied your request. The Plan says 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for a domiciliary visit provided on April 20, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that you can safely receive the care you need in another setting. 
 
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. You appear 
not yet be stable enough for transfer to a skilled nursing facility and should only require short-term additional 
acute care services that can safely be completed at the current facility. You do not require services at the 
LTACH that are not already available at the current facility. There are no services at the LTACH that you 
require that are not already available and covered at the current facility. Our physician reviewer found that your 
condition does not meet Medicare criteria for LTACH services. 
 
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.  
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (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 you need to go to a rehab center. The Plan denied 
your request. The Plan says that you can safely receive the services you need in other settings. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay 
with an interdisciplinary approach to rehabilitation care. You were admitted for cervical spine surgery. Your 
medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no 
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a roll-about semi-reclining chair (E1031).
You asked the Plan to pre-approve a roll-about semi-reclining chair. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 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 roll-about semi-reclining chair. Our reviewer says that the requested item does not appear to be medical in nature. Our physician reviewer found that it is unclear from the documentation available for review why the enrollee requires the requested chair over a wheelchair with elevated leg rests. We looked at this physician's review, the file, and Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Based on this information, we decided that Medicare rules for coverage of a roll-about semi-reclining chair have not been met. Therefore, we decided that the Plan does not have to pre-approve a roll-about semi-reclining chair (E1031).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically reasonable and necessary. 
The Plan denied your request. The Plan says rules for SNF care have 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 the beneficiary is a 78-year-old female with 
falls and leg pain without acute fracture. While there are identifiable skilled therapy service needs, there are no 
identifiable skilled nursing service needs. In addition, the enrollee does not require skilled nursing or therapy 
services on a daily basis. In conclusion, this beneficiary 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on August 14, 2020, 
by an OON provider. 
 
You asked the Plan to pay for the surgical pathology services. You say that the enrollee's blood work was 
unable to be processed by an in-network laboratory. The Plan denied your request. The Plan says 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 did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The 
record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to 
pay for the surgical pathology services provided on August 14, 2020, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) and unspecified preventive service (D1999) provided on May 26, 2021.
You asked the Plan to pay for the dental service. You say that you want to know what codes are covered for cleaning. The Plan denied your request. The Plan says the scaling and root planing are not listed as covered service. The Plan says the unspecified preventive service is not listed as a covered service either.
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 scaling and root planing, and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the scaling and root planing (D4341 x 2) and unspecified preventive service (D1999) provided on May 26, 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 meets the criteria for an IRF admission,
and these services are medically necessary. The Plan denied your request. The Plan says the criteria for
admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate setting.
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 that 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
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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 pre-approve a cervical spine MRI (72141).
You asked the Plan to pre-approve a cervical spine MRI. You say that the requested cervical spine MRI is medically necessary. The Plan denied your request. The Plan says the requested cervical spine MRI is not medically necessary.
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 a cervical spine MRI. Our reviewer says that the requested cervical spine MRI is not medically necessary. Our physician reviewer found there is no documentation of adequate conservative measures to include physical therapy. Criteria for the requested MRI have not been met. The requested cervical spine MRI is not 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 a cervical spine MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical spine MRI (72141).