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

We decided that the Plan has to pre-approve the catheter placement in coronary artery(s) for coronary angiography (93458).

You asked the Plan to pre-approve the catheter placement in coronary artery(s) for coronary angiography. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the requested procedure is not medically 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 catheter placement in coronary artery(s) for coronary angiography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee had a non-ST-elevation myocardial infarction (NSTEMI) in July 2021. The record indicates that the enrollee has uncontrolled diabetes, morbid obesity, and activity limiting chronic obstructive pulmonary disease. The enrollee has had a stress tested that demonstrates the presence of ischemia and wall motion abnormality. The provided records do support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are satisfied. 

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 catheter placement in coronary artery(s) for coronary angiography have not been met. Therefore, we decided that the Plan has to pre-approve the catheter placement in coronary artery(s) for coronary angiography (93458).

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).

You asked the Plan to pre-approve the intravenous moderate (conscious) sedation/analgesia. You say that you cannot afford to pay for these services. The Plan denied your request. The Plan says these services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

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 pre-approve intravenous moderate (conscious) sedation/analgesia (D9239 and D9243).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear coded 85060 provided on May 14, 2021.

You asked the Plan to pay for the blood smear. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. 

In this case, the CPT Code Manual definition of code 85060 is blood smear, peripheral, interpretation by physician with written report. 

We find that CPT code 85060 is not supported in the medical record. Specifically, this code has a professional component/technical component if 8. This means this code is not payable when billed to hospital outpatients or non-hospital enrollees. This code was billed with place of service 22 (outpatient hospital). This means this code is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the blood smear have not been met. Therefore, we decided that the Plan does not have to pay for the blood smear coded 85060 provided on May 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on April 14, 2021.
You asked the Plan to waive the copayment for the urgent care visit.. You say that you went to the urgent care center because you fell and scraped your nose. The urgent care center evaluated you and told you to go to the emergency room for further evaluation. You said that you were told there was no charge for the visit. You do not think you should have to pay a copayment for the urgent care visit because you already had to pay a copayment for the emergency room. The Plan denied your request. The Plan says you were charged this copayment 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 $30 copayment for urgent care visits. You have been asked to pay a $30 copayment for the urgent care visit.. This copayment applies regardless of the extent of services you receive at urgent care and regardless of whether you have to go to the emergency
room afterwards. 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 urgent care visit you had on April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for naturopathy services received on March 3, 2021.

You asked the Plan to pay for the services. You say that you would like the plan to verify the reimbursement process again. The Plan denied your request. The Plan says this was received from a non-Medicare certified retailer.

The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. 

The services at issue in this appeal are naturopathic services, and were provided by a provider who is not eligible with Medicare. Therefore, we decided that the Plan does not have to pay for naturopathy services received on March 3, 2021.
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 the SNF services. You say that the enrollee requires SNF care due to continued weakness, pain, and limited mobility. You say that the enrollee requires contact guard assistance and stability while ambulating. You say that a SNF denial puts the enrollee at risk for falls and injury at home. The Plan denied your request. The Plan says the enrollee does not have daily skilled nursing needs and is medically
stable. The Plan says that the clinical notes do not indicate that the enrollee requires services on an inpatient level in a SNF.
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 SNF services. 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. The enrollee is ambulating household distances and tending to activities of daily living with minimal supervision. Daily skilled services are not 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 
87541, 87581, 87640, 87798) provided on August 26, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan 
denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (87486, 87496, 87498, 87502, 87532, 87541, 87581, 
87640, 87798) provided on August 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 29, 2021, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from October 29, 2021, forward. You say that the 
services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are 
not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from October 
29, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of October 29, 2021, forward. Our physician reviewer found the 
enrollee did not require inpatient mental health treatment beyond October 29, 2021, as she was not a danger to 
herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve the enrollee's condition or for the 
purpose of diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from October 29, 2021, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 29, 
2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sacroiliac (SI) joint fusion procedure (27279). 
 
You asked the Plan to pre-approve SI joint fusion procedure. You say that this request is medically necessary. 
The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that the enrollee must have had a trial of at least one 
therapeutic intra-articular SI joint injection. 
 
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 fusion procedure. Our reviewer 
says that the requested procedure is not medically necessary. Our physician reviewer found the criteria for SI 
fusion have not met. There is no documentation of relief response from injections of SI joint. 
 
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 fusion procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the sacroiliac (SI) joint fusion procedure (27279).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crown (D2929), and core buildup (D2950), provided on February 9, 2021.
You asked the Plan to pre-approve the crown and core buildup. You say that you were billed the wrong amount The Plan denied your request. The Plan says the requested 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. Specifically, the services you obtained are not listed in the Plan's
benefit chart. Therefore, we decided that the Plan does not have to pre-approve the crown (D2929), and core buildup (D2950), provided on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urgent care services (procedure code 99072) provided to the enrollee on March 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 this is an unbundled 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, the CPT Code Manual definition of code 99072 is "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease." We find that CPT code 99072 is not supported in the medical record. Specifically, this code has a status indicator of "B" which means that payment for this code is always bundled into payment for other services not specified.
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 urgent care services (procedure code 99072) provided to the enrollee on March 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of interbody biomechanical device(s) coded 
22853 provided on October 13, 2020. 
 
You asked the Plan to pay for the insertion of interbody biomechanical device(s). 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. 
 
In this case, the CPT Code Manual definition of code 22853 is insertion of interbody biomechanical device(s) 
(eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), 
when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List 
separately in addition to code for primary procedure).
We find that CPT code 22853 is not supported in the medical record. Specifically, the operative report did not 
include documentation of an insertion of a interbody biomechanical device(s) (synthetic cage, mesh) with 
integral anterior instrumentation for device anchoring (screws, flanges) when performed, to intervertebral disc 
space in conjunction with interbody arthrodesis, for each interspace (listed separately in addition to code for 
primary procedure); therefore, this code cannot be verified. Based on this information, we decided that 
Medicare rules for coverage of the insertion of interbody biomechanical device(s) have not been met. 

Therefore, we decided that the Plan does not have to pay for the insertion of interbody biomechanical device(s) 
coded 22853 provided on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. He has multilevel lumbar disease, including spinal stenosis of moderate to severe severity. The record does not indicate that the enrollee's pain is relieved in flexion. The record does not indicate that the enrollee is not indicated for surgery at more than two levels. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve real-time mobile cardiac telemetry services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the records do not document that shorter-term heart monitoring had been performed and were not helpful.

The Plan must follow Medicare rules. Medicare rules say that electrocardiographic services are only covered under certain medical indications. 

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 you have a history of paroxysmal atrial fibrillation (AF), but you have not been continued on anti-coagulation. You have noted infrequent racing heart beats, and this could be recurrence of AF, which would necessitate long-term anti-coagulation and possibly further rhythm control therapy. Based on the limited symptoms and the importance of diagnosing recurrent AF in this case, which would necessitate long term anti-coagulation, use of a 30-day telemetry monitor meets coverage criteria, and is considered 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve real-time mobile cardiac telemetry services.

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: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pay for the chemotherapy administration provided on April 21, 2021.
You asked the Plan to pay for the chemotherapy administration. You say that these are billable and payable charges and were paid for the same patient on February 17, 2021. You say that the claim should be sent back for review. The Plan denied your request. The Plan says that there are more appropriate codes to describe the services provided.
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 record indicates that the Plan reviewed medical records to support the denial. The Plan has not forwarded any clinical information and we are unable to determine if the Plan was justified in denying the billed services. 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 chemotherapy administration provided on April 21, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a methylprednisolone acetate injection (J1030) provided on March 11, 2021.

You asked the Plan to pay for a methylprednisolone acetate injection. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.

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 J1030 is not supported in the medical record. Specifically, the submitted records do not include documentation of a methylprednisolone acetate injection being administered. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of a methylprednisolone acetate injection have not been met. Therefore, we decided that the Plan does not have to pay for a methylprednisolone acetate injection (J1030) provided on March 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services received from March 8, 2021 to April 14, 2021.
You asked the Plan to pay for the services. You say that nothing else has worked for your vertigo. The Plan denied your request. The Plan says you are not being treated for lower back pain by the acupuncturist.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the treatment was for vertigo. The services at issue in this case are only covered for chronic low back pain. Therefore, we decided that the Plan does not have to pay for acupuncture services received from March 8, 2021 to April 14, 2021.