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

We decided that the Plan does not have to waive the charges for the magnetic resonance imaging (MRI) of the breasts provided on August 14, 2020.
You asked the Plan to waive the charges for the breast MRI. You say that you feel that this should be considered preventive and be covered in full. The Plan denied your request. The Plan says this is not a covered screening service. This was correctly assessed the copayment for diagnostic radiology.
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 says that free screening for breast cancer is covered
for mammograms and clinical breast exams. Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic radiology, such as MRIs. You have been asked to pay a $50 copayment for the breast MRI. The breast MRI falls within the diagnostic radiology, such as MRIs benefit category, as only the services listed above are covered as screening. 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 charges for the magnetic resonance imaging (MRI) of the breasts provided on August 14, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 72110) provided to the enrollee on September 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 an appropriate modifier was not billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72110 is a column II code to column I code 72082. 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 imaging services (procedure code 72110) provided to the enrollee on September 22, 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 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 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 18 additional physical therapy (PT) visits.
You asked the Plan to pre-approve 18 additional PT visits. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 18 additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 18 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 18 additional physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chiropractic services (98941) provided
October 19, 2020.
You asked the Plan to waive the copayment for the chiropractic services. You say that the copayment should be
waived. The Plan denied your request. The Plan says the correct cost-sharing was applied.
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
copayment for Chiropractic Care.
You have been asked to pay a $20 copayment for the chiropractic services. The chiropractic services fall within
the Chiropractic Care 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 chiropractic
services (98941) provided October 19, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 99100) provided to the enrollee on September 2, 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 payment for this code is always bundled into payment for other services not specified, and no separate payment is made.

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 99100 is "Anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure)." 

We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. 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 anesthesia services (procedure code 99100) provided to the enrollee on September 2, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve lumbar epidural steroid injection (ESI) with imaging guidance
(62323).
You asked the Plan to pre-approve the lumbar ESI. You say that this procedure is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been
met.
The Plan follows Medicare rules. Medicare rules say that epidural steroid injections are subject to the criteria
listed 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 the lumbar ESI. Our reviewer says that
the requested procedure is medically reasonable and necessary. Our physician reviewer found the enrollee is a
74 year old female with chronic low back pain with lumbar radiculopathy to left lower extremity, lumbar spinal
stenosis with neurogenic claudication, and lumbar degenerative disc disease. The enrollee has exhausted
conservative therapy. Physical therapy has improved the enrollee's function, but not her pain. Pain is rated at
4/10 to 10/10. Magnetic resonance imaging revealed severe central spinal stenosis at multiple levels most
severe at L3-L4 and L4-L5. The provider has requested a left L4/L5 epidural steroid injection (ESI). In this
case, the member meets Medicare criteria. The requested procedure is appropriate for the treatment of this
patient's condition. The review has determined that it is reasonable and medically necessary for the enrollee to
have the requested lumbar ESI with imaging guidance.
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 lumbar ESI have been met. Therefore, we decided that the Plan has to preapprove
lumbar epidural steroid injection (ESI) with imaging guidance (62323).
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the clinical documentation reviewed does not indicate that this member
will be able to tolerate 3 hours of therapy per day for at least 5 days per week.
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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for respiratory failure,
coronavirus pneumonia, pulmonary embolism, and deep vein thrombosis. The enrollee's medical problems are
stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by mult iple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a
need for an intensive rehabilitation program. 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. Our
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa.

You asked the Plan to pre-approve Rhopressa. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Rhopressa.

Benefits for Rhopressa 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you are not ready to go home by yourself. The Plan denied your request. The Plan says that your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance angiography (MRA 70544) provided on August 12, 2021.
You asked the Plan to pay for MRA 70544. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 70544 has a procedure-to-procedure (PTP) edit of 1 with code 70551 so is not separately payable without an appropriate modifier.
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 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography (MRA 70544) provided on August 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy and occupational therapy
services (97535x4, 97530x24, 97110x24, 97112x24, 97116x24).

You asked the Plan to pre-approve additional physical therapy and occupational therapy services. You say that
the requested additional physical therapy and occupational therapy services are medically necessary. The Plan
denied your request. The Plan says the requested additional physical therapy and occupational therapy services
do not meet criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional physical therapy and
occupational therapy services. Our reviewer says that skilled services are not necessary to restore or maintain
function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has
had prior therapy. The enrollee has been authorized additional therapy and can transition to an independent
home exercise program and has caregiver support. There has been instruction on safety with mobility. The
requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of
a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional physical therapy and occupational therapy services have not been
met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy and
occupational therapy services (97535x4, 97530x24, 97110x24, 97112x24, 97116x24).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the retroperitoneal ultrasound (76775)
provided on August 31, 2021.

You asked the Plan to waive the copayment for the ultrasound. You say that this service was necessary and
should be covered in full by your Plan. The Plan denied your request. The Plan says this claim was covered and
processed correctly at the in-network benefit level. According to your contract, you are responsible for a $160
copayment for ultrasounds. Because the Plan's allowed amount (discounted rate) is less than the required
copayment in this case, you are being asked to pay a lesser 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 $160
copayment for Medicare-covered diagnostic radiological services.

You have been asked to pay $98.69 for the ultrasound. An ultrasound falls within the Medicare-covered
diagnostic radiological services 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 retroperitoneal ultrasound (76775) provided on August 31, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the morphometric analysis (88361) provided on June 3, 2021.
You asked the Plan to pay for the morphometric analysis. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says this service is not being used as a companion diagnostic.
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 pay for the morphometric analysis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the member does not have a history of cancer. Current high quality evidence does not support that this form of testing/biopsy will lead to significantly improved long-term outcomes compared to standard testing methods for this clinical scenario. 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 morphometric analysis have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis (88361) provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visits provided on March 3, 2021, and March 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the rest home visits. You say that these services were ordered by the facility, and the physician should not be penalized for providing medically necessary care. The Plan denied your request. The Plan says these services were provided OON without a request for 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 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 rest home visits provided on March 3, 2021, and March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 21,
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 provider did not bill as required by Medicare coding regulations.
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 74176 is a column II code to column I code 74177. 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 imaging services provided to the enrollee on August 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on August 30, 2021.
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain/ceramic crown. You say that your dentist recommended these procedures because you had no other medical options. The Plan denied your request. The Plan says these services are not covered under your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.
Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain/ceramic crown (D6058) provided on August 30, 2021.