Persius/hicric huggingface dataset:
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 requested admission to a SNF is medically
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet
criteria.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 the enrollee does not require daily skilled
nursing services and the specialized skill, knowledge and judgment of a skilled professional nurse are not
required to safely and effectively provide medically necessary and reasonable treatment. Services in the home
or in an assisted living facility with home health care or in a long-term care facility on a part time basis appear
appropriate in this case.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hematology services to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve the OON hematology services. You say that you were treated for low
platelets while in the hospital and wish to continue to follow-up with this hematologist for this issue. The Plan
denied your request. The Plan says you have an established hematology provider in the network who can
assume post-hospital follow-up care. There is no medical need to be referred for OON outpatient hematology
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
hematology services to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to reduce the copayment for the skilled nursing facility (SNF) stay provided by a
network facility from July 14, 2021, to July 27, 2021.
You asked the Plan to reduce the copayment for the SNF stay. You say that you are appealing this claim
because the enrollee was overcharged. The Plan denied your request. The Plan says that you have been asked to
pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). The enrollee's contract with the Plan says that enrollees must pay a
$0 copayment per day for days 1-20 and a $178 copayment for days 21-100.
The Plan says the enrollee must pay a $2,202 copayment for the SNF stay. Based on the plan contract,
however, the enrollee cannot be asked to pay more than a $1,246 copayment for the SNF stay. See chart below.
Dates of Service Service SNF Days Copayment Day Count Member
Liability
June 7, 2021, to
June 21, 2021
SNF stay
(first stay)
1-14 $0 14 $0
July 14, 2021, to
July 19, 2021
SNF stay
(second
stay)
15-20 $0 6 $0
July 20, 2021, to
July 27, 2021
SNF stay
(second
stay)
21-28 $178 7 $1,246 - Please
note, you are
not charged for
the discharge
date of service.
Total $1,246
Therefore, we decided that the Plan has to reduce the copayment for the skilled nursing facility (SNF) stay
provided by a network facility from July 14, 2021, to July 27, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered on June 16, 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 you have exhausted the benefit limit.
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an annual
wellness visit (AWV) once every 12 months.
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case.
Therefore, we decided that the Plan does not have to pay for the annual wellness visit rendered on
June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with codes A6530,
A6539, A6545.
You asked the Plan to pre-approve the compression stockings. You say that these are necessary to treat your
condition. The Plan denied your request. The Plan says these are not covered for your condition by Medicare.
The Plan must follow Medicare rules. The rules say that compression stockings described by codes A6530 and
A6539 are noncovered because they do not meet the statutory definition of a surgical dressing. Compression
stockings described by code A6545 are only covered when used for a qualifying venous stasis ulcer.
Although these items may be appropriate, they do not fall into a covered benefit category for your condition
and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-
approve compression stockings identified with codes A6530, A6539, A6545.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 457 additional home health aide visits.
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 services are not medically necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a history of Alzheimer's disease with ataxia and has been
receiving visits since at least November of 2021. There is no indication she had a further decline in function
that would require additional home health aide services. There is no indication that she has a feeding tube,
parental medications, or complex wound care issues. She had no recent decline in function and is medically
stable. She does not require additional home health aide services to effectively provide treatment, care, and/or
services in order to improve her condition, perform a maintenance program to maintain the her condition and/or
prevent deterioration. The additional 457 visits are 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve 457 additional home health aide visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation for sacro-iliac joint pain
provided on June 4, 2021.
You asked the Plan to pay for the radiofrequency ablation for sacro-iliac joint pain. You say that the
radiofrequency ablation for sacro-iliac joint pain provided on June 4, 2021, was medically necessary. The Plan
denied your request. The Plan says the radiofrequency ablation for sacro-iliac joint pain provided on
June 4, 2021, was not medically necessary.
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 radiofrequency ablation for sacro-iliac
joint pain. Our reviewer says that the radiofrequency ablation for sacro-iliac joint pain provided on June 4,
2021, was not medically necessary. Our physician reviewer found radiofrequency ablation (RFA) of the sacro-
iliac (SI) joint is considered experimental/investigational because of the wide variation of efficacy reported in
the literature. Therefore, the procedure was 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 radiofrequency ablation for sacro-iliac joint pain have not been met.
Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation for sacro-iliac joint
pain provided on June 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services.
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 services are not medically necessary. The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has a tracheotomy for
which she has been receiving home health care for two years. There is no documentation of a recent change in
her health status or needs. Daily needs do not meet the definition of intermittent, and the failure to progress
after two years of services makes ongoing daily services 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional home health services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tracheostomy, fenestration procedure with skin flaps
(31610-59) provided on June 22, 2021.
You asked the Plan to pay for code 31610-59. You say that the medical records support the use of modifier -59
billed with code 31610 provided on June 22, 2021. The Plan denied your request. The Plan says the medical
records do not support the use of modifier -59 billed with code 31610 provided on June 22, 2021.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.
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 code 31610-59. Our reviewer says that the
medical records do not support the use of modifier -59 billed with code 31610 provided on June 22, 2021. Our physician reviewer found the operative report describes a tracheostomy was performed, followed by a
tracheobronchoscopy through an established tracheostomy incision to confirm placement of tracheotomy tube,
suction performed, and placement of inner cannula, and cuff inflated. To cite the operative report: "Flexible
bronchoscopy via tracheostoma tube revealed the tracheotomy tube to be well positioned and properly above
the carina"; "The suction catheter passed well beyond the tip of the tracheotomy tube and retrieved tracheal
secretions"; "the inner cannula was placed, the cuff was inflated". The operative report does not support these
procedures as distinct procedures, and therefore should not be reported separately.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 31610-59 have not been met. Therefore, we decided that the Plan does not
have to pay for the Tracheostomy, fenestration procedure with skin flaps (31610-59) provided on
June 22, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Introduction of needle or intracatheter, upper or lower
extremity artery (36140) and Angiography, extremity, bilateral, radiological supervision and interpretation
(75716) provided on September 13, 2021. You asked the Plan to pay for codes 36140 and 75716. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 36140
and 75716 are column II codes to column I code 37229. This claim has not been billed with an appropriate
modifier to bypass the edit. The operative report does not support CPT 36140 as a separate procedure from the
primary procedure. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we
decided that the Plan does not have to pay for the Introduction of needle or intracatheter, upper or lower
extremity artery (36140) and Angiography, extremity, bilateral, radiological supervision and interpretation
(75716) provided on September 13, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the retroperitoneal ultrasound rendered on
September 9, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 76770 (retroperitoneal ultrasound) and 93976 (vascular
study). Code 76770 is a column II code with a modifier indicator of 1 when billed with column I code 93976.
Code 76770 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided
that the Plan does not have to pay for the retroperitoneal ultrasound rendered on September 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the continued inpatient
psychiatric care is medically necessary. The Plan denied your request. The Plan says the continued inpatient
psychiatric care does not meet criteria.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment. 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 continued inpatient psychiatric care.
Our reviewer says that the service is not medically necessary. Our physician reviewer found it did not appear
that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond
the date in question. You were not shown to be a danger to yourself or others. You were not showing any
auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats
the safety.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on October 26, 2021 by an out-of-
network (OON) provider.
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 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 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 drug testing provided on October 26, 2021 by
an out-of-network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure.
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 services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is
considered experimental in nature, as more research is needed to support efficacy. The services are therefore
not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.

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 services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has mild anemia. Her hemoglobin is 11.1, which does not meet the criteria for Aranesp. The services are not safe and effective and reasonable and 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic knee (L5859, L5856, L5828, L5321) to be
provided by an out-of-network provider.
You asked the Plan to pre-approve a prosthetic knee (L5859, L5856, L5828, L5321) to be provided by an out-
of-network provider. You say that the requested prosthetic knee provided while out of the Plan's service area is
medically necessary. The Plan denied your request. The Plan says the requested prosthetic knee provided while
out of the Plan's service area is not medically necessary.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and
pre-approved care 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 a prosthetic knee (L5859, L5856,
L5828, L5321) to be provided by an out-of-network provider. Our reviewer says that the requested prosthetic
knee provided while out of the Plan's service area is not medically necessary. Our physician reviewer found the
documentation does not support that the enrollee has an emergency and urgently needed services. The Plan
states that there are in network providers that can provide the requested service within a reasonable distance
from the enrollee's location. Medicare criteria for out of area services to be covered have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a prosthetic knee (L5859, L5856, L5828, L5321) to be provided by an out-of-
network provider have not been met. Therefore, we decided that the Plan does not have to pre-approve a
prosthetic knee (L5859, L5856, L5828, L5321) to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that your recovery is slower than you hoped, you can't use the bathroom and your home is being renovated for a wheelchair. You say that you would be returning home unsafely if you are discharged. The Plan denied your request. The Plan says you no longer require skilled services and the continuation of SNF 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have no identifiable skilled nursing needs or skilled therapy needs. 

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 continued SNF care.