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

We decided that the Plan does not have to pre-approve outpatient sacroiliac joint fusion.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the imaging does not exclude other causes for the symptoms.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures (as there is no documentation of any physical therapy having been tried and failed.) Additionally, the imaging studies, including magnetic resonance imaging (MRI) and x-rays, do not demonstrate any significant sacroiliac joint pathology. MRI denotes significant lumbar spine pathology. All other plausible causes of pain have not been ruled out. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for outpatient sacroiliac joint fusion 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve outpatient sacroiliac joint fusion
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the water, washcloths, diapers, gloves, booties, and sales tax received from August 11, 2021 to August 25, 2021.
You asked the Plan to pay for the water, washcloths, diapers, gloves, booties, and sales tax. You say that you would like these claims paid by the Plan. The Plan denied your request. The Plan says the items received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. In addition, the rules say that for equipment to be covered, it must primarily serve a medical purpose. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. In addition, the items at issue in this appeal do not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the water, washcloths, diapers, gloves, booties, and sales tax received from August 11, 2021 to August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an addition to an endoskeletal system, below the knee, alignable system (L5910) for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the previously approved preparatory prosthesis is a non-alignable system and the progress note in the medical records does not provide medical justification for the requested alignable system.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the L5530 preparatory prosthesis is a non-alignable system and therefore the L5910, Addition, endoskeletal system, below knee, alignable system cannot be used with this preparatory prosthesis and would exceed the enrollee's medical need. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an addition to an endoskeletal system, below the knee, alignable system (L5910) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection procedure (96372) provided on February 18, 2021.
You asked the Plan to pay for injection procedure 96372. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 96372 has a procedure-to-procedure (PTP) edit value of 1 with code 20552 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 injection procedure 96372 is a column II code to column I code 20552. 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 injection procedure (96372) provided on February 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 24, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not separately payable.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate.
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for
the laboratory services provided on February 24, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you will not improve without in-house therapy and your current treatment does not help to improve your condition. You state you are in need of intense physical in-house therapy. The Plan denied your request. The Plan says you have not had a change in function that needs daily skilled therapy services. The Plan states you do not have any daily skilled nursing needs. The Plan states you do not need daily skilled services to be provided only on an inpatient basis in a SNF. The Plan states your needs may be met at home with home health services and supervision or in a long-term care setting with part-time skilled services, if approved by your health plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have been residing at home with home health care services. You continue to require a lot of assistance for self-care tasks and mobility. You appear to have increased needs for custodial care. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your new baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records show that you have not completed your full course of care in the hospital and your records show you that you are not medically stable for discharge. The Plan states the treatments you currently require are more frequent and intensive than what is available at a SNF. The Plan states you need to stay in an acute care hospital until you are medically cleared for discharge.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out-of-network (OON) provider on August 25, 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 office visit (99204) rendered by the out-of-network (OON) provider on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional high compression bandages (A6452) for the enrollee.
You asked the Plan to pre-approve the bandages. You say that this is medically necessary. The Plan denied your request. The Plan says the frequency of replacement would be no more than one per week unless they are a part of a multi-layer compression bandage system.
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 bandages. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation received from provider does not indicate any medical necessity for additional bandages above the Medicare allowable benefit. In this case, per the coverage criteria, the frequency of replacement would be no more than one per week unless they are a part of a multi-layer compression bandage system. The review has determined that the enrollee does not need more than usual supply of these bandages. 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 bandages have not been met. Therefore, we decided that the Plan does not have to pre-approve additional high compression bandages (A6452) for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec (J3490).
You asked the Plan to pre-approve Nurtec. You say that the enrollee has tried and failed Ubrelvy. You also say that you would like 8 tablets of Nurtec approved for the enrollee for 30 days. The Plan denied your request. The Plan says Nurtec is not covered under the enrollee's medical plan.
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 Nurtec (J3490).
Benefits for Nurtec 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast reconstruction.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary and not a cosmetic issue. The Plan denied your request. The Plan says given the persistent issues despite multiple breast revisions, it is unclear how another revision would be helpful.
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 surgery. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, the record indicates that the enrollee has undergone exchange prosthesis, bilateral breast
reconstruction revision with capsulectomies, bilateral implant exchange, bilateral placement of AlloDerm and
repair of lateral mammary folds since her initial mastectomies. The record indicates that the enrollee does not
have a contracture and likely has chronic neuropathic pain that would not be improved by surgery. The record
indicates that the requested service is for appearance and is therefore cosmetic. 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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve breast reconstruction.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulator supplies (A4595), provided on
December 11, 2018.
You asked the Plan to pay for the electrical stimulator supplies. You say that the items are medically necessary.
The Plan denied your request. The Plan says only two units of A4595 can be approved, the remaining two units
of A4595 have been denied.
The Plan must follow Medicare rules. Medicare rules say that a separate allowance will be made for
replacement supplies when they are reasonable and necessary and are used with a covered transcutaneous
electrical nerve stimulation (TENS) device. Usual maximum utilization is:
2 TENS leads - a maximum of one unit of A4595 per month.
4 TENS leads - a maximum of two units of A4595 per month.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the electrical stimulator supplies have not been met. Therefore, we decided that the Plan does not
have to pay for the electrical stimulator supplies (A4595), provided on December 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on June 8, 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 covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension kit) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on June 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you need skilled nursing care to help improve your current level of care. The Plan denied your request. The Plan says you do not need daily skilled services to be provided only on an inpatient basis in a SNF. The Plan states your needs can be met at a lower level of care. The Plan states your needs may be met in long-term care, if approved by your health plan.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and have been receiving skilled rehabilitation services in an inpatient rehabilitation facility (IRF). You no longer require daily skilled nursing and/or skilled therapy services. You could benefit from continued intermittent services at a lower level of care. Although you made slow progress with therapy, your functional improvement has plateaued, there is no indication that transfer to a skilled nursing facility is required. You can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care. There are no services offered at a SNF that are not offered at an IRF. Admission to a SNF for inpatient skilled rehabilitation services is not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the mandibular partial denture (D5214) provided on August 4, 2021.
You asked the Plan to pay for the mandibular partial denture. You say that you were not advised that your benefits had changed. You also say that the partial you had was over 15 years old. The Plan denied your request. The Plan says this service is not a covered benefit 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 mandibular partial denture (D5214) provided on August 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight assay rendered on August 23, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed
adjacent to the CPT code for GeneSight testing.
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX
Z-Code. 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 GeneSight assay rendered on August
23, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (procedure code 99053) provided to the enrollee on April 10, 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 service is bundled into payment for other services.
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 99053 is "Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service." We find that CPT code 99053 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 the medical services (procedure code 99053) provided to the enrollee on April 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services (97110), the application of a finger
splint (29130), and orthotics (97760) provided from July 14, 2021 to July 21, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for therapeutic services, the application of finger splint, and orthotics. You say that
the services provided were medically necessary and the medical records are enclosed for review. The Plan
denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says
that they have also determined that these services are not urgent or emergent, nor were they approved in
advance.
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 therapeutic services (97110), the application of a finger splint (29130), and orthotics (97760) provided from July 14, 2021 to July 21, 2021 by an out-of-network (OON) provider