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

We decided that the Plan does not have to pay for the emergency room services provided on April 29, 2021.
You asked the Plan to pay for the services provided. You say that all emergency patients are entitled to care.
The Plan denied your request. The Plan says the claim processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate 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 a bundled service.
Payment for covered services is always bundled into payment for other services not specified. Based on this
information, we decided that Medicare rules for coverage of the services provided have not been met.
The file shows that CPT code 99283 was billed with code 99285. CPT Code 99283 may be eligible for
payment when billed with this code pair. However, the claim does not show that code 99283 was billed with a
modifier that is suitable for payment. Based on this information, we decided that the Medicare rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the emergency room
services provided on April 29, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital and received oral medications and had stable vital signs. You received physical and occupational therapy. You need some assistance with functional mobility, including walking to 95 feet with a rolling walker. You need varied assistance with activities of daily living. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on January 27, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is 
not payable. 
 
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the 
procedure is covered for an assistant and the person who assists the surgery bears the designation of a 
physician, PA, NP, or CNS. 
 
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, 
or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of
practitioners. Therefore, we decided that the Plan does not have to pay for the assistant surgeon services 
provided on January 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation of the prostate 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 requirements were not met.

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 criteria has not been met, as the enrollee is over 80 years old and has not failed three months of therapy. Additionally, the enrollee has neurogenic bladder. 

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 transurethral waterjet ablation of the prostate for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional bilateral interlaminar epidural steroid 
injection 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 this service can only be billed and reimbursed once per date of service. 
 
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 requested for one injection (procedure code 62323) has been approved. The health plan feels that the 
service is reasonable and medically necessary for the evaluation and treatment of the enrollee with radicular 
low back pain. However, per the coverage criteria, the rules say that it is not expected that a patient would 
undergo an epidural injection at more than two levels (unilateral or bilateral) on any given date of service. The 
review has determined that the enrollee does not meet the criteria for this additional epidural steroid injection. 
 
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 additional bilateral interlaminar epidural steroid injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 12-month supply of Boost formula.
You asked the Plan to pre-approve a 12-month supply of Boost formula. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation. The items you asked the Plan to pre-approve are considered nutritional supplements. Although these may be appropriate, neither Medicare nor the Plan provides coverage for them. Therefore, we decided that the Plan does not have to pre-approve a 12-month supply of Boost formula.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
January 12, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have 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 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 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 physician services provided to the 
enrollee on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of imaging services (procedure codes 70450 
and 72125) provided to the enrollee on March 27, 2021. 
 
You asked the Plan to pay for the additional units. You say that this should be paid for, as it was not a duplicate 
charge. The Plan denied your request. The Plan says there is no additional documentation supporting additional 
studies which were billed and remain denied. 
 
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 70450: 
 
Computed tomography, head or brain; without contrast material 
 
CPT 72125: 

Computed tomography, cervical spine; without contrast material 
 
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 additional units. Our reviewer says that the services at 
issue in this case were not supported by the medical records. Our reviewer found the documentation shows that 
CPT 70450 and 72125 were both billed twice. There is no documentation to support that these procedures were 
performed twice. There is no appropriate modifier in this case to support billing both procedures twice. 
 
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 additional units have not been met. Therefore, we decided that the Plan does 
not have to pay for additional units of imaging services (procedure codes 70450 and 72125) provided to the 
enrollee on March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on March 4, 2021.

You asked the Plan to pay for pathology services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is paid under the outpatient prospective payment system (OPPS) to the hospital.

The Plan must follow Medicare rules. Medicare rules say that payment may be made under the physical fee schedule for the professional component of physician laboratory or pathology services furnished to hospital outpatients, but payment is not made for technical component services.

We looked at the file and Medicare rules. These services were billed globally (for both the professional component and technical component); however, Medicare only covers the professional component for pathology services performed on hospital outpatients. Based on this information, we decided that Medicare rules for coverage of pathology services have not been met. Therefore, we decided that the Plan does not have to pay for pathology services provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the office services. You say that the Health Plan does not have the specialist
to treat the enrollee's condition. The Plan denied your request. The Plan says they will not refer the enrollee to
an out-of-network neuromuscular specialist for treatment because the services are available in Plan and the
enrollee is contractually required to obtain this service from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 office services to be provided by an out-of-network provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve L4-5 decompression and discectomy (CPT code 63030)
for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the enrollee underwent a left lumbar L4-5 discectomy (spine surgery) on March 16,
2021. The Plan states there is no imaging evidence of a large recurrent herniation (bulging disc in the spine).
The Plan states the enrollee has not trialed any postoperative (after surgery) ESIs (spine injections) which are
one of the first choices for management of postoperative scar tissue. The Plan states a spinal laminectomy is
not reasonable or necessary and this request has been denied.
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 items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the criteria for revision surgery not met. A lumbar injection is most appropriate at this time.
More conservative measures are needed.
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 L4-5 decompression and discectomy (CPT code 63030) for the enrollee
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 these services are medically necessary. The Plan denied your request. The Plan says that your care does not require inpatient 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services provided on February 24, 2021, to 
March 17, 2021, by an OON provider. 
 
You asked the Plan to pay for the services provided. You say that you thought areas other than the low back 
could be considered. The Plan denied your request. The Plan says acupuncture for the treatment of any 
condition other than low back pain is not covered. 
 
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 rules say that Medicare offers limited coverage for 
acupuncture treatments for chronic low back pain meeting certain requirements. 
 
The file shows that the enrollee received acupuncture services for progressive neuropathy. The provider in this 
case is not a network provider with the Plan. The enrollee was not being treated for chronic low back pain. 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 acupuncture services provided 
on February 24, 2021, to March 17, 2021, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on June 15, 2021.
You asked the Plan to pay for gingival irrigation. You say that when you visited the provider, you were not advised that the provider was not in network. The Plan denied your request. The Plan says the service at issue in this appeal is not covered by the member's contract.
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 gingival irrigation (D4921) provided on June 15, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required
to establish a maintenance program or to prevent deterioration of your condit ion. Your care needs, as a
practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on August 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve catheter based atrial fibrillation ablation.
You asked the Plan to pre-approve atrial fibrillation ablation. You say that you are requesting that either this denial decision is overturned or set up a peer-to-peer review with a practicing cardiologist/electrophysiologist. The Plan denied your request. The Plan says the request does not meet the criteria as the enrollee is required to be taking a Class 1 or III anti arrhythmic agents per policy and the enrollee is not on (and has not trialed) a Class 1 or III anti arrhythmic agents.
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 atrial fibrillation ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case the record indicates that the enrollee has rate controlled recurrent atrial fibrillation. The record does not indicate that the enrollee is symptomatic. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied and the requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of atrial fibrillation ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve catheter based atrial fibrillation ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for out-of-network audiology office visits 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 is a network audiology provider available.

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 referral for out-of-network audiology office visits for the enrollee.