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

We decided that the Plan does not have to pay for lab services (G0480, 80307) provided on March 2, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were provided out-of-network and were not emergent or pre-
authorized.
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 services 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 these services. Therefore, we decided
that the Plan does not have to pay for lab services (G0480, 80307) provided on March 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast material (CPT code 70551), for the enrollee.
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says this was denied because the Plan did not receive laboratory work, cognitive testing, depression screening, drug and alcohol screening, or question of head trauma in the notes sent by the enrollee's doctor.
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 the MRI. Our physician reviewer found the enrollee appears to have some indications for explaining the symptoms such as severe depression, combination of benzodiazepines and opioid use, which is not recommended, and recent viral illness. There was no plan to change these variables first and no indication for MRI at this time. Therefore, the brain MRI will be considered not medically necessary 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, brain (including brain stem); without contrast material (CPT code 70551), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve tests (95822, 95861) provided February 17, 2021.
You asked the Plan to pay for the nerve tests. You say that the services were medically necessary. The Plan
denied your request. The Plan says the codes billed share bundled relationships with other codes 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, we have confirmed that a bundled
relationship exists between codes 51785 and 95822 and 51785 and 95861. This claim has not been billed with
an appropriate modifier to bypass the edit.
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan
does not have to pay for nerve tests (95822, 95861) provided February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left knee orthosis.
You asked the Plan to pre-approve a left knee orthosis. 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 follows Medicare rules. Medicare rules say that a knee orthosis, with an adjustable flexion and
extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are
covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s).
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 left knee orthosis. Our reviewer says
that the item is not medically necessary. Our physician reviewer found the requested L1843 is not medically
necessary per LCD L33318. There is no evidence of abnormal joint laxity or instability of the left knee on a
physical exam. There is no evidence of a recent surgery or injury to the knee. The enrollee is noted ambulatory
but there is no evidence the enrollee requires the requested knee brace.
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 left knee orthosis have not been met. Therefore, we decided that the Plan does
not have to pre-approve a left knee orthosis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee does not have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the rituximab-abbs injection,10 mg (Q5115) provided May 4, 2021 to May 14, 2021.
You asked the Plan to waive the copayment for the injection services. You say that you do not understand why you are paying for treatment that has been completely covered in the past. The Plan denied your request. The Plan says the claim was processed with the correct cost share applied per the Evidence of Coverage.
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 $725.85 for the injection services. The injection services fall 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 copayment for the rituximab-abbs injection,10 mg (Q5115) provided May 4, 2021 to May 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a panoramic dental X-ray (D0330) provided on July 13,
2021.
You asked the Plan to pay for a panoramic dental X-ray. You say that you did not give permission for a
panoramic dental X-ray. The Plan denied your request. The Plan says rules for payment have not been met.
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. The Plan covers one set of
panoramic or complete intra-oral X-rays every 36 months.
We looked at the file, the Plan contract, and Medicare rules. Based on this information, we decided that the
Plan's rules for coverage of a panoramic dental X-ray have not been met. Specifically, the record shows that
you received complete intra-oral X-rays on the same date of service. The benefit for panoramic or intra-oral X-
rays has therefore been exhausted. Therefore, we decided that the Plan does not have to pay for a panoramic
dental X-ray (D0330) provided on July 13, 2021.
Your complaint about receiving services from the provider which you did not request nor authorize 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: 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 IRF care is medically reasonable and necessary. The
Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found the patient was admitted for surgical management of a hip fracture after a fall.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is
no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable
expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontic (D6245) and two abutment supported retainers (D6068 x2) provided on August 5, 2021.
You asked the Plan to pay for the pontic and abutment supported retainers. You say that you would like to appeal these services. The Plan denied your request. The Plan says these services are not allowed because they were performed by a provider who has chosen to opt out of Medicare. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.
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 pontic (D6245) and two abutment supported retainers (D6068 x2) provided on August 5, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records do not show that you need to be seen by a rehabilitation doctor at least three (3) times a week or need the care of an intensive team (rehabilitation doctor and nurse, social worker, and therapists) for your care. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.
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 you do not require a physical medicine and rehabilitation (PMR) physician's
supervision three times a week in an IRF. You have no acute rehabilitation nursing needs. Based upon your current level of function, you do not require intensive therapies, consisting of at least three (3) hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. IRF admission is not medically necessary. Document does not support the necessity for admission. While you may benefit from physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility (SNF). 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 IRF admission and services.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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. Our
physician reviewer found There is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (44604) provided on January 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 44604 is "Suture of large intestine (colorrhaphy) for
perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy".
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the services. Our reviewer says that the use of code 44604 is
not supported by the records provided.
Our reviewer found that the medical records provided do not include sufficient documentation to validate that a
"Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or
multiple perforations); without colostomy" was performed on January 25, 2021. Therefore, this service cannot
be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (44604) provided on January 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0480, 80307) provided on June 1, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says there were network providers available.
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 services 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
these services. Therefore, we decided that the Plan does not have to pay for lab services (G0480, 80307)
provided on June 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa viscosupplementation injections.
You asked the Plan to pre-approve the Euflexxa injections. You say that the enrollee has had success with steroid injections but these have been less effective over time. The Plan denied your request. The Plan says there has been no three-month trial of conservative therapy including physical therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the Euflexxa injections. Our reviewer says that the requested use of this agent is not considered medically reasonable and necessary at this time. Our physician reviewer found the imaging evidence shows only mild to moderate knee arthritis. Radiographically, there is no severe joint disease. As such, the use of this treatment is not supported. 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 Euflexxa injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa viscosupplementation injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve the Euflexxa. You say that it is felt this is necessary. The Plan denied your
request. The Plan says there has not been a failure of any of the preferred agents.
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 Euflexxa. Our reviewer says that the
requested use of Euflexxa brand viscosupplement is not medically necessary based on step therapy criteria. Our
physician reviewer found the Plan requires a trial of drug other viscosupplements before they will approve the
requested drug. In this case, the patient has not tried and failed the required drugs, Synvisc or Durolane. 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 Euflexxa have not been met. Therefore, we decided that the Plan does not
have to pre-approve Euflexxa injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy (D3330) provided on August 20, 2021.
You asked the Plan to pay for the endodontic therapy. You say that you went to the dentist for an abscess, not a root canal. You also say that you had to return for a second cleaning (root canal) because you were on an antibiotic for the infection. The Plan denied your request. The Plan says this procedure is not a benefit under the dental plan.
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 endodontic therapy (D3330) provided on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your condition has improved, and you are able to care for yourself.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued inpatient services from December 10, 2021, forward were requested. 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 continued services. Our physician reviewer found that it was not expected that you would improve in a reasonable period of time as you did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations.
You were compliant with treatment while not showing any acute threats to safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.