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

We decided that the Plan does not have to pre-approve radiofrequency ablation services to be provided at more than two spinal levels.
You asked the Plan to pre-approve radiofrequency ablation services. You say that this procedure is medically necessary as requested. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that radiofrequency ablation procedures are limited to one or two levels unless there a specific unique medical necessity for more than two levels. 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 radiofrequency ablation services. Our reviewer says that the requested procedure is not medically necessary and reasonable. Our physician reviewer found this 88-year-old woman has chronic neck pain and cervical spinal stenosis. She had two sets of diagnostic medial branch blocks (MBBs) performed which covered 3 levels. The LCD limits utilization of radiofrequency ablation to 2 levels bilaterally per session unless there is a unique circumstance presented in the medical records for the enrollee's specific condition. There are no specific criteria that supports this request for radiofrequency ablation services to more than 2 levels.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services to be provided at more than two spinal levels.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography (93306), provided on June 7, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the echocardiography.. You say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization must be obtained for services rendered at an out-of-network provider.
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 the echocardiography (93306), provided on June 7, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on
October 17, 2020, through October 22, 2020.

You asked the Plan to waive the copayment for the inpatient hospital care. You say that the service should be
covered. The Plan denied your request. The Plan says the cost share was applied 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 $345 copayment each day one through five for inpatient hospital care.

The enrollee has been asked to pay a $345 copayment each day one through five for the inpatient hospital care.
the inpatient hospital care falls within the inpatient hospital care benefit category. 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 waive the copayment for the inpatient hospital care provided on October 17, 2020, through October 22,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for spine surgery for the enrollee.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are no out-of-network benefits, and the services are readily available in-network.
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 spine surgery for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on May 5, 2021.

You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. 

We find that CPT codes G0483 and 80307 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 and 80307 provided on May 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a colonoscopy and esophagogastroduodenoscopy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a colonoscopy and esophagogastroduodenoscopy to be provided by an OON provider. You say that you were told in the past that this provider is in network. The Plan denied your request. The Plan says this provider is OON and there are in network providers who can perform the requested services.
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 a colonoscopy and esophagogastroduodenoscopy to be provided by an out-of-network (OON) provider
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the medical eye exam. We decided that the Plan does not have to pay
for the fundus photography with interpretation and report.
You asked the Plan to pay for the medical eye exam. You say that you would like these claims reprocessed and
approved for payment. The Plan says that the claims have previously processed correctly.
We decided that the Plan has to pay for the medical eye exam.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. In this case, the Plan has failed to articulate why the claim for 92014 would be
included as paid under the claim for date of service January 27, 2021 for code 92012. These represent different
circumstances and are not duplicate. No reason was provided why 92014 would be included in payment for
92012 Therefore, we decided that the Plan has to pay for the medical eye exam.
We also decided that the Plan does not have to pay for the fundus photography with interpretation and
report.
The Plan follows Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We find that CPT code 92250 is not supported in the record. Specifically, the record indicates that this is an
exact duplicate of the same claim that has been processed and paid. Therefore, we decided that the Plan does
not have to pay for the fundus photography with interpretation and report.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient home visit (99349) provided on May 24, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the established patient home visit. You say that these services were medically reasonable and necessary. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 the established patient home visit (99349) provided on May 24, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the injection (J0178), provided on April
26, 2021.
You asked the Plan to waive the coinsurance for the injection. You say that the service was medically
necessary. The Plan denied your request. The Plan says the cost share was applied 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). Your contract with the Plan clearly says that you must pay a 20%
coinsurance for Medicare Part B prescription drugs.
You have been asked to pay a 20% coinsurance for the injection. the injection falls within the Medicare Part B
prescription drugs benefit category. This means that you have been asked to pay the correct amount based on
your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled
in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection
(J0178), provided on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network mental health services.
You asked the Plan to pay for these services. You say that you were referred by your physician. The Plan denied your request. The Plan says it was confirmed by your primary care physician that you self-referred and they did not issue a referral for this service.
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 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 out of network mental health services provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 20, 2021, by an OON
provider.
You asked the Plan to pay for the services provided. You say that the testing was medically necessary. The
Plan denied your request. The Plan says utilization of network providers and authorization for certain services
are required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 did not pre-approve the services 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 the lab services provided on May 20, 2021, by an OON provider.
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 this is medically necessary. The Plan denied your
request. The Plan says the services can be received in other settings.
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 complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
non-surgical management of a tib-fib fracture and a shoulder dislocation after a fall. Medical problems are
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the medical record supports a need for physical and/or occupational therapy, there is no
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different
level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from
the intensive rehabilitation therapy program provided in an IRF.
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 waive the copayment for the arthrocentesis provided from May 21,
2021, to June 18, 2021.
You asked the Plan to waive the copayment for the arthrocentesis. You say that you did not know there was a
facility charge. The Plan denied your request. The Plan says you have been asked to pay the correct costsharing
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 $295
copayment for Medicare-covered surgical services at an outpatient hospital.
You have been asked to pay a $295 copayment for the arthrocentesis. The arthrocentesis 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 the arthrocentesis provided
from May 21, 2021, to June 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xiidra drops for the enrollee.
You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Xiidra drops for the enrollee
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 services are the fastest way to get the enrollee back on his feet. The Plan denied your request. The Plan says criteria for admission to the IRF setting 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee 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: Drugs
Decision: Favorable

We decided that the Plan has to hold you harmless for the insertion of an intrauterine device (IUD) (58300), and the levonorgestral-releasing intrauterine contraceptive system (Mirena) (J7298), 52 mg provided on May 12, 2021.
You asked the Plan to hold you harmless for Mirena. You say that the Mirena IUD is not related to contraception. You say that this is for treatment of endometrial cancer. You say that it was determined you are not a good candidate for surgery. You also say that this claim should be reconsidered. The Plan denied your request. The Plan says that the services were not billed per Medicare guidelines. The Plan also says that as a result the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules. You were referred for Mirena by a contract provider. The file does not show that the Plan provided notice that Mirena would not be covered. Under Medicare rules, this means Mirena is considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the insertion of an intrauterine device (IUD) (58300), and the levonorgestral-releasing intrauterine contraceptive system (Mirena) (J7298), 52 mg provided on May 12, 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for speech therapy services provided by a speech-language pathologist on January 24, 2020.
You asked the Plan to pay for the speech therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if the services are not available from preferred providers. You say that the in-network benefits should be honored, and the claim should be processed for payment. The Plan denied your request. The Plan says the code is not appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a physician/ non-physician practitioner (NPP) services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the speech therapy services have not been met. Specifically, there is no evidence that the billing nurse practitioner was present at the time the services were rendered. Therefore, we decided that the Plan does not have to pay for speech therapy services provided by a speech-language pathologist on January 24, 2020