Persius/hicric huggingface dataset:
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87641, 87798, 88305, 88312) provided 
on December 1, 2020. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this was billed with an incorrect 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 (87641, 87798, 88305, 88312) provided on December 1, 
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal fusion revision (22612, 20937, 22830, 22849).
You asked the Plan to pre-approve the spinal fusion revision. You say that the procedure 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 a spinal fusion revision is covered when the time since the prior surgery has been at least 1 year. 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 spinal fusion revision. Our reviewer says that the requested procedure is not medically necessary. Our physician reviewer found the record indicates that the enrollee has radicular low back pain after a prior L2-S1 fusion on June 1, 2021. One year has not passed since the surgery. The elements of the coverage criteria are not 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 spinal fusion revision have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal fusion revision (22612, 20937, 22830, 22849).
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 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services represented by code 99100 provided 
on February 24, 2021. 
 
You asked the Plan to pay for code 99100. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. Code 99100 has a status code of "B" under the Medicare Physicians 
Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as 
payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided 
that the Plan does not have to pay for the anesthesia services represented by code 99100 provided on February 
24, 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 the IRF services are medically necessary. The Plan denied your request. The Plan says 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 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. 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 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. The Plan denied your request. The Plan says the IRF services are not medically necessary. 
 
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.

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) guidance rendered on April 
12, 2021 to April 14, 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 77014 (CT guidance for placement of radiation therapy 
fields) and 77301 (intensity modulated radiotherapy plan). Code 77014 is a column II code with a modifier indicator of 1 when billed with column I code 77301. Code 
77014 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 computed tomography (CT) guidance rendered on April 12, 2021 to April 
14, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device at L3-L4 and L4-L5 for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy.
There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as discussed above. FDA indications include implantation of the Superion device at one or two adjacent lumbar levels in patients with moderate spinal stenosis in whom operative treatment is indicated at no more than two levels, from L1 to L5. This enrollee has multiple degrees of spinal stenosis, many not at FDA indicated levels of "moderate" spinal stenosis (including the planned level of implantation L3-L4 and L4-L5). FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of spinal instability on flexion/extension films. There is no documentation of the Cobb angle. There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous device at L3-L4 and L4-L5 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device at L3-L4 and L4-L5 for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the knee; 4 or more views (73564)
rendered by the OON provider on April 15, 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 x-ray exam of the knee; 4 or more views (73564) rendered by the OON provider
on April 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from March 5, 2021, to March 27, 2021.
You asked the Plan to pay for home health services. You say that this was billed correctly. The Plan denied your request. The Plan says this was not billed with a Q code on the date of the first visit.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. The location where services were provided must always be reported along with the first visit reported on the claim. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, while a Q code was billed to report the service location, it was not billed on the date of the first visit. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from March 5, 2021, to March 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to issue payment for the proton treatment delivery; intermediate (77523), the 
radiation treatment management (77427), the stereoscopic x-ray guidance (G6002), and the continuing medical 
physics consultation (77336) provided on April 19, 2021. 
 
You asked the Plan to issue payment for these services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says that the copayment has been applied 
correctly to the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Medicare rules say that MAOs pay the enrollee the difference 
between original Medicare cost-sharing incurred for qualified clinical trial items and services and the MA 
plan's in-network cost-sharing for the same category of items and services. The enrollee's contract with the 
Plan says that enrollees must pay a $25 copayment for radiation therapy provided at a specialist's office, 
outpatient hospital, or freestanding radiological facility.  
 
Based upon the review of the plan contract, we find that the Plan must pay the difference between the original 
Medicare cost-sharing incurred for the qualified clinical trial services provided and the plan's in-network cost 
sharing for the same category of services. After Medicare issued payment, the Plan liability is $285.77  
minus the $25 applicable copayment, which is $260.77. Therefore, we decided that the Plan has to issue 
payment for the proton treatment delivery; intermediate (77523), the radiation treatment management (77427), 
the stereoscopic x-ray guidance (G6002), and the continuing medical physics consultation (77336) provided on 
April 19, 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at a 24-hour facility, in addition to basic service (99053) provided on June 25, 2021.
You asked the Plan to pay for code 99053. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Code 99053 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Therefore, we decided that the Plan does not have to pay for the service(s) provided between 10:00 PM and 8:00 AM at a 24-hour facility, in addition to basic service (99053) provided on June 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the diagnostic colonoscopy provided at an 
ambulatory surgery center on February 19, 2021. 
 
You asked the Plan to reduce the copayment for the diagnostic colonoscopy. You say that this is a higher 
copayment than seems appropriate for the charges.  You stated that the enrollee cannot afford this copayment. 
The Plan denied your request. The Plan says the enrollee was 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). The enrollee's contract with the Plan clearly says that enrollees 
must pay a $265 copayment for diagnostic colonoscopies at an ambulatory surgery center.  
 
The enrollee has been asked to pay a $265 copayment for the diagnostic colonoscopy. This means that the 
enrollee has been asked to pay the correct amount based on the contract with the Plan.  
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, 
we decided that the Plan does not have to reduce the copayment for the diagnostic colonoscopy provided at an 
ambulatory surgery center on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (POV) (group 1 standard,
patient weight capacity up to and including 300 pounds) (K0800).
You asked the Plan to pre-approve a group one POV. You say that the item is medically necessary. The Plan
denied your request. The Plan says there has been no evaluation of your ability to operate a scooter/power
operated vehicle (POV) without having an accident. There is no evaluation of your home to see if it is able to
accommodate a POV and there is no evaluation of your ability to safely transfer to and from a POV.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 group one POV. Our reviewer says
that the service is not medically necessary. Our physician reviewer found there was no documentation that the
enrollee could safely operate a POV or that the patients home could accommodate a POV.
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 group one POV have not been met. Therefore, we decided that the Plan does
not have to pre-approve a power operated vehicle (POV) (group 1 standard, patient weight capacity up to and
including 300 pounds) (K0800).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia solution, 60 mg/ml. 
 
You asked the Plan to pre-approve Prolia. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says the requested drug is not being given by or supervised by the physician. The 
Plan says that the provider is not supplying the medication either. The Plan also says that the requested drug is 
not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia solution, 60 mg/ml.  
 
Benefits for Prolia 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral sacroiliac joint radiofrequency ablation 
procedures (64625 x 2). 
 
You asked the Plan to pre-approve the outpatient services. You say that the requested treatment is medically 
necessary. The Plan denied your request. The Plan says the requested treatment 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 pre-approve the outpatient services. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is experiencing chronic low back pain with radiation down her legs; she 
also has sacroiliitis. The reviewer found that the requested service is considered experimental and/or 
investigational therapy. Therefore, the reviewer found that the requested procedures are deemed not medically 
reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the outpatient services have not been met. Specifically, the requested 
procedures are considered experimental and investigational. Therefore, we decided that the Plan does not have 
to pre-approve bilateral sacroiliac joint radiofrequency ablation procedures (64625 x 2).