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

We decided that the Plan does not have to pay for the services (71045) provided on August 31, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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, we have confirmed that code 71045
is a column II code to column I code 71046. 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 the services (71045) provided on August 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided by an in-network provider on March 26, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that the ultrasound was related to coronavirus treatment, and you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $100 copayment for Medicare-covered radiological diagnostic services, not including x-rays, performed in an in-network physician's office or at an in-network free-standing facility (such as a radiology center or medical clinic). You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. Please note, there is no provision in the contract which states a copayment will be waived for services related to the coronavirus. 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 ultrasound provided by an in-network provider on March 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not
meet Medicare criteria for coverage of the IRF 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. Our
physician reviewer found you do not require the intensity of services provided at an IRF.
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. Your care needs can be met 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not
meet Medicare criteria for coverage of the requested IRF 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. Our
physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MSH2 full gene sequencing rendered on April 3, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 81295 (MSH2 full gene sequencing) and 81432 (hereditary breast cancer panel). Code 81295 is a column II code with a modifier indicator of 1 when billed with column I code 81432. Code 81295 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the MSH2 full gene sequencing rendered on April 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for skin lesion destruction provided on October 22, 2021.  You asked the Plan to waive the copayment for the lesion destruction. You say that the provider advised you that there would not be a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $25 copayment for each surgical service received in a specialist office.   The file shows that you had the procedure done in a specialist office. Therefore, you have been asked to pay a $25 copayment for the lesion destruction. The lesion destruction falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 skin lesion destruction provided on October 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical fusion surgery.
You asked the Plan to pre-approve neck surgery. You say that this surgery is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of this service.
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 neck surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of adequate physical therapy for neck pain. There are no red flags for surgery at this time. More conservative measures are needed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neck surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical fusion surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2311, E2377, E2313).  You asked the Plan to pre-approve the expandable controller. You say that the expandable controller is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that expandable controllers are covered when 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 expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the records show that the enrollee has adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.  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 expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller for a power wheelchair (E2311, E2377, E2313).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural steroid injections (62323).
You asked the Plan to pre-approve epidural steroid injections. You say that the repeat injections are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that for repeat injections, medical records must document at least 50% sustained improvement in pain relief and/or improvement in function measured from baseline using same scale for at least 3 months We looked at the file and Medicare rules. At least 3 months have not passed since the last set of injections. Based on this information, we decided that Medicare rules for coverage of epidural steroid injections have not been met. Therefore, we decided that the Plan does not have to pre-approve epidural steroid injections (62323).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy service (90834) rendered by the out-of-network (OON) provider on September 28, 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 psychotherapy service (90834) rendered by the out-of-network (OON) provider on September 28, 2021.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pre-approve the additional injections and monitored anesthesia. We decided that the Plan does not have to pre-approve monitored anesthesia care.
You asked the Plan to pre-approve the additional injections and monitored anesthesia. You say that the services are medically necessary. The Plan says that coverage criteria has not been met.
We decided that the Plan has to pre-approve additional medial branch block injections. We also decided that the Plan does not have to pre-approve monitored anesthesia care.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are covered when 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 additional injections and monitored anesthesia. Our reviewer says that while the additional injections are medically necessary, there is no indication for monitored anesthesia. Our physician reviewer found a second set of diagnostic medial branch blocks is necessary and medically reasonable. However, the patient does not have an indication for monitored anesthesia care. Records do not support that this service is 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 the additional injections and monitored anesthesia have been met. Therefore, we decided that the Plan has to pre-approve additional medial branch block injections. We decided that the Plan does not have to pre-approve monitored anesthesia care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says IRF coverage criteria has 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 based on the records 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) of the thorax (71250) provided on October 1, 2021.
You asked the Plan to pay for the CT of the thorax. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 71250 and 71275.
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 code 71250 is a column II code to column I code 71275. 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 the computed tomography (CT) of the thorax (71250) provided on October 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.
You asked the Plan to pre-approve Prednisone. You say that Prednisone is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit of Medicare.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prednisone.
Benefits for Prednisone may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553) and receiver (K0554), provide don June 9, 2021.
You asked the Plan to pay for the CGM supplies and receiver. You say that the item is medically necessary. The Plan denied your request. The Plan says the documentation submitted did not sufficiently support the billed supply code; nor did it indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. the documentation submitted does not indicate medical necessity for the purchased item; nor does it show the provider discussed the need for it. 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 the continuous glucose monitor (CGM) supplies (K0553) and receiver (K0554), provide don June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your
request. The Plan says there is a low pre-test probability of coronary artery disease.
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 imaging. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found you pre-test probability for an abnormal test is low and your electrocardiogram shows an interpretable
pattern. There is no evidence provided that would support the need for adionuclide stress testing. In summary,
there is insufficient documentation to support the medical necessity for the requested radionuclide cardiac
stress testing in this enrollee's clinical management.
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 imaging have not been met. Therefore, we decided that the Plan does not
have to pre-approve myocardial perfusion imaging.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you would like reconsideration because the requested SNF services are medically necessary. The Plan denied your request. The Plan says that you do not meet Medicare criteria for coverage of the requested SNF services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that you have documented skilled nursing needs. You receives overnight enteral feeding, daily catheter/perineal care and sacral wound care. Our physician reviewer found daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services beyond
February 11, 2022.
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 admission 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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to the SNF on
February 1, 2022 after treatment for encephalopathy complicated by a fall and a cervical spine fracture and
right wrist injury. As of February 7, 2022 she is walking 20 feet with assistance of two and a platform rolling
walker. She is medically stable and her therapy is reported to be limited by significant confusion, poor safety
awareness, and poor judgment. She has no skilled nursing needs. She has skilled therapy needs but does not
require skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary
services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve continued skilled nursing facility (SNF) services beyond February 11, 2022.