Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan
denied your request. The Plan says that the complexity of your nursing, medical and rehabilitation needs do not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
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 a stroke. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Synvisc-One injections.
You asked the Plan to pre-approve the Synvisc-One injections. You say that the treatment is medically
necessary for the enrollee's knee pain. The Plan denied your request. The Plan says step therapy requirements
have not been met.
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 Synvisc-One injections. Our reviewer says that the requested use of Synvisc-One is not considered medically necessary based on step therapy criteria. Our physician reviewer found the Plan requires a trial of drug Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 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 Synvisc-One injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Synvisc-One injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64493 and 64494 provided on
May 5, 2021.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT codes 64493 and 64494 is 1. The MAI value for this code is 2. You billed 2
units of each of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules
for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to
pay for the injection services coded 64493 and 64494 provided on May 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Monovisc (J7327) provided on August 2, 2021.
You asked the Plan to waive the coinsurance for Monovisc. You say that you were told by the provider's office that there would be no cost to you. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $263.94, or 20% of the Medicare-allowed total charge of $1,319.70, for Monovisc. Monovisc falls within the "Medicare Part B prescription drugs" 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 coinsurance for treatment with Monovisc (J7327) provided on August 2, 2021.
Your complaint about receiving inaccurate or incomplete information about your cost-sharing responsibilities from the provider is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve the requested services. You say that the enrollee is in constant pain. The
Plan denied your request. The Plan says there has not been a second confirmatory set of diagnostic medial
branch blocks.
The Plan must follow Medicare rules. Medicare rules say that facet joint interventions are only covered under
certain medical indications.
We looked at the file and Medicare rules. The medical records provided show that the enrollee received a
medial branch block on November 2, 2021. The records do not indicate that a second medial branch block was
provided. Based on this information, we decided that Medicare rules for coverage have not been met.
Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain.
You asked the Plan to pre-approve an MRI of the brain. 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. 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 an MRI of the brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested service is not medically necessary and reasonable for the diagnosis and treatment for your clinical condition at this time. 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 an MRI of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64494-LT and 64494-RT) provided on
July 7, 2021.
You asked the Plan to pay for facet joint injections. You say that medical records support this service. The Plan
denied your request. The Plan says the denial of payment for these services is correct, because code 64494 has
a medically unlikely edit (MUE) value of 1 meaning that this billing exceeds allowable units of service for
coverage.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value cannot be paid when the MAI value is 2.
In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. It may be appropriate to instead bill this procedure as a single unit bilaterally (e.g., 1
unit of 64494-50) Based on this information, we decided that Medicare rules for coverage of facet joint
injections have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections
(64494-LT and 64494-RT) provided on July 7, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the head.
You asked the Plan to pre-approve MRI. You say that you have brain cancer and have undergone brain surgery,
chemotherapy, and radiation so it is very important to have this test done. The Plan denied your request. The
Plan says that the denial of authorization for this service is correct, because this 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 MRI. Our reviewer says that you meet
criteria for the requested MRI test. Our physician reviewer found the anaplastic nature of your tumor makes it
highly likely to recur. For that reason - and since recent scans show equivocal findings - closer than usual
follow-up is 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve
magnetic resonance imaging (MRI) of the head.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from June 8,
2020, through June 12, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for
reconsideration of adjustment. The Plan denied your request.
The Plan says payment of DRG 871 is not supported. The Plan states review supports DRG 178. The Plan
states principal diagnosis code assignment
of A41.9, Sepsis, unspecified organism and Secondary diagnosis code assignment of J96.01, Acute respiratory
failure with hypoxia were reported by the hospital. The Plan states according to coding guidelines and
documentation in the medical record this condition did not qualify for reporting, and the determination to
remove principal and secondary diagnosis codes A41.9 and J96.01 is upheld.
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 principal diagnosis code assignment of A41.9,
Sepsis, unspecified organism. and Secondary diagnosis code assignment of J96.01, Acute respiratory failure
with hypoxia. 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 physician reviewer found the review indicates that the documentation supported an admission for
Pneumonitis due to inhalation of food and vomit. The documentation was inconsistent/unclear regarding a
diagnosis of sepsis and acute respiratory failure with hypoxia. Even though sepsis and acute respiratory failure
with hypoxia are documented on progress notes, supporting medical record documentation was not found
within the record. The review has determined that the following diagnoses codes were not supported by the
records: principal diagnosis code assignment of A41.9, sepsis, unspecified organism, and secondary diagnosis
code assignment of J96.01, acute respiratory failure with hypoxia.
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 to the enrollee from June 8, 2020, through June 12,2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing (81542) provided on December 29, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 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 there are currently no clinical indications for this technology and its current role remains uncertain. The requested laboratory test is not medically necessary or indicated. 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 testing (81542) provided on December 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided July 1, 2020, to July 5, 2020.
You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the DRG billed is not supported by the documentation.
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 assignment of J96.01
Acute respiratory failure with hypoxia. 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
inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician
reviewer found the documentation supported an admission for hypertensive heart disease with heart failure.
The documentation was unclear regarding a diagnosis of acute respiratory failure. Even though acute
respiratory failure was documented on the Emergency Room note, history and physical, and day one progress
note, supporting medical record documentation was not found within the record. The enrollee presented from
the nursing home with complaints of shortness of breath. Chest X-ray showed pulmonary vascular congestion
and enrollee had an elevated brain natriuretic peptide (BNP). Acute congestive heart failure exacerbation was
suspected. The enrollee was given a dose of Intravenous Pyelogram Lasix. Per Emergency Room provider
note, "in no distress" and "tachypnea noted." Although acute respiratory failure was diagnosed, it was not
present throughout the medical record and not listed as a diagnosis on the discharge summary. There was no
documentation of persistent hypoxia. The enrollee did not require treatment consistent with acute respiratory
failure such as high flow oxygen administration, provision of Bilevel Positive Airway Pressure (BiPAP), and/or
use of mechanical ventilation. Per history and physical, "no respiratory distress." As noted above, although the
provider documented acute respiratory failure, reasonable support within the health record must be present for
that diagnosis. Therefore, the DRG billed is not supported by the documentation.
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 the inpatient services provided July 1, 2020, to July 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been
exhausted. Therefore, coverage criteria have not been met.
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 60 one-way transportation trips when each one-way trip does not exceed
75 miles.
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 pre-approve additional routine transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ilio-hypogastric nerve injection.
You asked the Plan to pre-approve ilio-hypogastric nerve injection. 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 ilio-hypogastric nerve injection. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the indication for this injection is not documented in the notes submitted.
The request 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 ilio-hypogastric nerve injection have not been met. Therefore, we decided that
the Plan does not have to pre-approve ilio-hypogastric nerve injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140), extractions (D7210 x 2), incision and drainage of abscess (D7511), and unspecified preventive service (D1999) provided on June 24, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that this was your second dentist visit for the year. You say that this was an emergency. You say that you were in extreme pain. You say that you paid $785 out of pocket. You also say that the dentist refunded you $155. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan says that the frequency limit has been exceeded. The Plan also says that out of network providers may bill you for any amount greater than what the plan pays the provider. The Plan says that
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 and the services are listed as covered, the frequency limit for the limited oral evaluation has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on January 5, 2021. Additionally, out of network providers may bill you for any amount greater than what the plan pays. Therefore, we decided that the Plan does not have to pay an additional amount for the limited oral evaluation (D0140), extractions (D7210 x 2), incision and drainage of abscess (D7511), and unspecified preventive service (D1999) provided on June 24, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee brace (L1820) provided on April 19, 2021.
You asked the Plan to pay for a knee brace. You say that the item at issue was a medical necessity for the
enrollee. The Plan denied your request. The Plan says rules for payment for durable medical equipment have
not been met.
The Plan must follow Medicare rules. The rules state that the information in the patient's medical record must
adequately support the medical necessity for the item.
The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. The record shows that the Plan made several attempts to obtain the necessary documentation
without success. Therefore, we decided that the Plan does not have to pay for a knee brace (L1820) provided on
April 19, 2021