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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says movement to a skilled nursing facility 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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered on December 8, 2020.
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 procedure codes J3411, J3415, J3490, J1955, J3490-KP and J3490-KQ are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The definition of code J3415 is injection, pyridoxine hcl, 100 mg. The definition of code J3490 is unclassified drugs. The definition of code J1955 is injection, levocarnitine, per 1 gm.
We find that procedure codes J3411, J3415, J3490, J1955, J3490-KP and J3490-KQ are not supported in the medical record. Specifically, the records show that a nutria-pharmaceutical blend was administered and separate billing of these drugs it not appropriate. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug services rendered on December 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bilateral cluneal nerve block.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a procedure not accepted as a standard of medical practice is not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has chronic low back pain. She takes Gabapentin, Lidocaine ointment, and Voltaren gel for pain. She has tried physical therapy, electrical nerve stimulation, and bracing. There is insufficient evidence in the peer reviewed literature to support this procedure. Therefore, the request is deemed 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a bilateral cluneal nerve block.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on March 30, 2021.

You asked the Plan to pay for the office visit. You say that you were not aware that prior authorization was needed. The Plan denied your request. The Plan says that no prior authorization was obtained.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the Evidence of Coverage. This means we cannot determine if the Plan's denial of non-emergent services is supported. Therefore, we decided that the Plan has to pay for the office visit provided on March 30, 2021.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the ice therapy device purchased on December 17, 2020.

You asked the Plan to reimburse you for the cold therapy device and cold wrap. You say that you should not have to pay for a device that was mandatory for you to have after surgery. The Plan denied your request. The Plan says the cooling therapy items do not fit the definition of reasonable and necessary and are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. The devices are not covered by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the ice therapy device purchased on December 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for Magnetic resonance imaging (MRI) and Computed Tomography (CT) scans (70551, 72141, 74176) provided October 13, 2020 to January 18, 2021.
You asked the Plan to waive the copayments for the MRI's and CT scan. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were applied.
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 $150 copayment for Diagnostic Radiology. You have been asked to pay two $150 copayments for the MRI's and the Medicare allowable amount of $133.99 for the CT scan. The Medicare allowable amount is less than the $150 copayment. 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 copayments for Magnetic resonance imaging (MRI) and Computed Tomography (CT) scans (70551, 72141, 74176) provided October 13, 2020 to January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a LINX device.
You asked the Plan to pre-approve implantation of a LINX device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 implantation of a LINX device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has a Hill grade 3-4 3cm hiatal hernia and gastroesophageal reflux. The record indicates that the enrollee had a negative Bravo pH test and has a DeMeester score of 12.6. 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 implantation of a LINX device have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a LINX device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided from October 6, 2020, to November 24, 2020.
You asked the Plan to pay for these services. You say that this provider is in network and these services should be covered by the Plan. The Plan denied your request. The Plan says this provider and the services billed are not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The 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 physician services provided from October 6, 2020, to November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.
You asked the Plan to pre-approve SI joint radiofrequency ablation. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 SI joint radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested SI joint radiofrequency ablation 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 SI joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on February 25, 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 separately payable.
The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable.
The provider submitted a claim for procedure codes 82465 (assay of cholesterol, serum or whole blood) and
80061 (lipid panel). Code 82645 is a column II code with a modifier indicator of 0 when billed with column I
code 80061. Code 82645 is not separately payable.
The provider submitted a claim for procedure codes 83718 (assay of lipoprotein) and 83701 (lipoprotein,
blood; high resolution fractionation and quantitation of lipoproteins). Code 83718 is a column II code with a
modifier indicator of 0 when billed with column I code 83701. Code 83718 is not separately payable.
The provider submitted a claim for procedure codes 84478 (assay of triglycerides) and 80061. Code 84478 is a
column II code with a modifier indicator of 0 when billed with column I code 80061. Code 84478 is not
separately payable.
Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 25,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device provided to the enrollee on March 25, 2021.
You asked the Plan to pre-approve the device. You say that this should be paid for. The Plan denied your request. The Plan says payment for this service would have been included in the facility payment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the device is being requested for use in a SNF or hospital. The device cannot be reported separately for payment. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device provided to the enrollee on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower commode.

You asked the Plan to pre-approve a shower commode. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not primarily medical in nature. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a shower commode.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from April 1, 2020 to April 23, 2020.
You asked the Plan to pay for the SNF services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. The file shows that the claim was billed with Revenue Code 0222,
which is incorrect. The correct Revenue Code is 0022. The total charges should be zero for Revenue Code 0022. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from April 1, 2020 to April 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine foot care provided on September 24, 2020.

You asked the Plan to pay for the routine foot care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered for your condition.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the routine foot care have not been met. Therefore, we decided that the Plan does not have to pay for the routine foot care provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99203) provided February 5, 2021.

You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

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 99203 is not supported in the medical record. Specifically, payment for this service is included in the global period for CPT 28010 and cannot be paid separately. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99203) provided February 5, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve shoulder surgery.
You asked the Plan to pre-approve shoulder surgery. You say that the services are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 shoulder surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has magnetic resonance imaging (MRI) evidence of shoulder pathology to be addressed with the surgery. The records show she has had physical therapy and has been seen multiple times for shoulder pain. The surgery should be approved. It is reasonable and medically appropriate at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder surgery have been met. Therefore, we decided that the Plan has to pre-approve shoulder surgery.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on January 4, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the office visit (99215) rendered by the out-of-network (OON) provider on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing care provided January 1, 2021.

You asked the Plan to waive the copayment for the skilled nursing care. You say that the copayment should be waived due to COVID-19. The Plan denied your request. The Plan says there is no copayment waiver due to COVID-19 for inpatient rehabilitation services. The correct copayment was applied.

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 $184 per-day copayment for days 21 to 100 of skilled nursing care. 

You have been asked to pay a $184 per day copayment for day 21 of skilled nursing care. 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 skilled nursing care provided January 1, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a Polysomnography (95810) provided March 10, 2021.
You asked the Plan to pay for the Polysomnography. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
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 95810 is not supported in the medical record. Specifically, no evaluation and management service was reported with the service. Based on this information, we decided that Medicare rules for coverage of the Polysomnography have not been met. Therefore, we decided that the Plan does not have to pay for a Polysomnography (95810) provided March 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on September 26, 2020.
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 procedure code 99291 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of
the first 30-74 minutes of critical care time spent on the enrollee. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pay for the critical care services rendered on September 26, 2020.