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

We decided that the Plan does not have to pay for the laboratory services rendered on June 2, 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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy performed on August 26, 2021.
You asked the Plan to waive the copayment for the colonoscopy. You say that you feel that you should not be billed this much since you had the procedure at an ambulatory surgical center. 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 $350 copayment for each date of service for surgical procedures provided at an outpatient hospital facility. The file shows that the procedure took place in an outpatient hospital setting.
Therefore, you have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers 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 a colonoscopy with biopsy performed on August 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on May 22, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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 the denied codes is: CPT 51785: Needle electromyography studies (EMG) of anal or urethral sphincter, any technique CPT 95937: Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method
Healthcare Common Procedure Coding System (HCPCS) G0453: Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) 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 services at issue in this case were not supported by the medical records. Our reviewer found in terms of CPT 5187, the documentation does not describe internal needle electrodes technique used to perform a needle electrode EMG of anal sphincter, and cannot be confirmed as performed. In terms of CPT 95937 and HCPCS G0453, these codes have a PTP edit indicator of I when reported with each other. The modifiers associated with NCCI are allowed with this PTP code pair when appropriate. 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 neurophysiology services provided to the enrollee on May 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a revascularization procedure.
You asked the Plan to pre-approve revascularization. You say that the enrollee needs this procedure to open the
veins in her legs. The Plan denied your request. The Plan says the denial of authorization for this service,
because the records do not show narrowing of the veins.
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 revascularization. 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 plan for treatment of the tibial arteries in the provider's assessment. As
there is no significant disease in the vessel in question and no plan for its treatment, the code in question cannot
be considered 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 revascularization have not been met. Therefore, we decided that the Plan does
not have to pre-approve a revascularization procedure.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology consultation services provided on February 24, 2021, billed with two units of code 88321.
You asked the Plan to pay for the two additional units of code 88321. You say that this should be paid. The Plan denied your request. The Plan says this cannot be paid at more than one unit.
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 88321 is 1 unit. The MAI value for this code is 2. You billed three units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the two additional units of code 88321 have not been met. Therefore, we decided that the Plan does not have to pay for the pathology consultation services provided on February 24, 2021, billed with two units of code 88321.
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 need daily nursing or daily therapy 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from March 24, 2020
to March 27, 2020.
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 DRG is not supported.
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 DRG 417 (laparoscopic cholecystectomy without
C.D.E. with MCC). We looked at the file and Medicare rules. There are no submitted records to support the
billing of DRG 417. Based on this information, we decided the file does not substantiate the DRG as billed.
Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from
March 24, 2020 to March 27, 2020.
Appeal type: Imaging
Decision: Partially Favorable

We decided that the Plan has to pay for the Medicare allowed amount for the CT scans. We decided that the Plan does not have to pay for any balance in excess of the Medicare allowed amount for the CT Scans.
You asked the Plan to pay for the Medicare allowed amount for the CT scans. You say that you would like reconsideration based on the records submitted. The Plan says that the primary carrier's payment of $676.80 is higher than the Medicare allowable fee maximum of $146.71.
We decided that the Plan has to pay for the Medicare allowed amount for the CT Scans.
The Plan follows Medicare rules. Medicare rules say that for services paid on a fee schedule, Medicare secondary payment amounts are determined by a formula and, in this case, is the amount Medicare would pay if the services were not covered by a primary payer. We looked at your request, the file and Medicare rules. Secondary payers are responsible for paying the lowest of the excess of the actual charge minus the primary payment, the amount Medicare would pay if the services were not covered by a primary payer or the higher of the Medicare payment amount or the primary payers allowable charge minus the amount actually paid by the primary payer. In this case, the lowest amount is the Medicare allowed amount. The Plan is responsible for paying the Medicare allowed amount in this case. Therefore, we decided that the Plan has to pay for the Medicare allowed amount for the CT Scans.
We also decided that the Plan does not have to pay for any balance in excess of the Medicare allowed amount for the CT Scans.
The Plan is only responsible for paying the lowest of three scenarios. In this case, the Plan is responsible for paying the Medicare allowed amount. Therefore, we decided the Plan does not have to pay any amount in excess of the Medicare allowed amount.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
You asked the Plan to pre-approve these services. You say that you recommend this minimally invasive procedure when conservative treatment has failed and as a safer alternative to a laminectomy or spinal fusion procedure. The Plan denied your request. The Plan says that these services are contraindicated for the enrollee.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency nerve ablation procedure (C9753, C9752).
You asked the Plan to pre-approve the radiofrequency nerve ablation procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this procedure is experimental and non-covered.
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 radiofrequency nerve ablation procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental. More studies are needed to show safety and efficacy. 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 radiofrequency nerve ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency nerve ablation procedure (C9753, C9752).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on February 25, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that this was medically necessary. The Plan denied your request. The Plan says this was not 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (80307, G0483) provided on February 25, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says needs can be at a lower level of 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 that in this case, the enrollee's nursing, medical and rehabilitation needs do not
require an acute rehab hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational
therapy, at an intensive rehabilitation therapy program. There is not a reasonable expectation that this
individual will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an inpatient rehabilitation facility. The enrollee continues to have a need for skilled therapy with
ongoing safety concerns and a potential for functional improvement however, the documentation doesn't
support that he would meet criteria for admission to an acute inpatient rehabilitation facility. There is no
indication that the enrollee would require skilled rehabilitation in an IRF, participating in rehab services 15
hours a week, under the supervision of a physician with at least 3 visits weekly to regain or maintain his/her
functional status. He is near his prior level of function and can receive services 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary as there is appropriate care available in plan.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (InSpan) procedure.
You asked the Plan to pre-approve InSpan. You say that you have an enormous amount of pain everywhere in your body. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is unproven and there is 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 InSpan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the InSpan device is experimental, more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of InSpan have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (InSpan) procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement of a continuous positive airway pressure device (CPAP) device 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 the request for replacement is not reasonable and necessary as the enrollee must work with the durable medical equipment provider and manufacturer for a solution.
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 the enrollee's current device was recalled by the manufacturer. The records do not indicate any difficulty with the device, or that it is more than five years old. In this circumstance of a manufacturer's recall, the manufacturer is responsible for replacement or repair, not the insurer or Medicare. 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 a replacement of a continuous positive airway pressure device (CPAP) device for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser treatment rendered on August 9, 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 procedure codes 96920 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 96920 is laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm. We find that CPT code 96920 is not supported in the medical record. Specifically, the records do not support that the code was used for reporting psoriasis treatment. 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 pay for the laser treatment rendered on August 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an OON
provider.
You asked the Plan to pre-approve the chiropractic services. You say that you need the chiropractic services
because of degenerative disk disease and chronic neck and lower back pain. Chiropractic services has helped
alleviate your pain in the past. The Plan denied your request. The Plan says enrollee's must receive their
medical services from an in-network provider with the exception being urgent or emergent services. The Plan
has
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the chiropractic services to be provided by an OON provider.