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

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services. You asked the Plan to pre-approve the SNF services. You say that you still need nursing wound care. The Plan denied your request. The Plan says the guidelines for a continuation of SNF care have not been met. The Plan says that the enrollee no longer requires daily skilled 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee's stay in the SNF was not reasonable and not medically necessary for a patient who has debility from recent illness. The enrollee did not need any nursing care other than routine care. The documentation does not support the need for a stay in a SNF with daily skilled therapies in an inpatient setting at the current level of function. The enrollee's care needs could be safely provided at an alternate and lower intensity setting such as in a long-term care facility with intermittent therapies. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
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 you still need help and have no family that is nearby to help. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit (J0885).
You asked the Plan to pre-approve Procrit. You say that Procrit is medically necessary for the enrollee. The
Plan denied your request. The Plan says the enrollee has not tried and failed the preferred step therapy drug,
Retacrit.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Procrit. Our reviewer says that Procrit
is not medically necessary. Our physician reviewer found the provided documentation did not indicate that the
enrollee has tried and failed the preferred drug, Retacrit. The reviewer also found that there is no indication that
the plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Procrit have not been met. Specifically, the file does not indicate that the
enrollee has tried and failed the preferred drug, Retacrit. Therefore, we decided that the Plan does not have to
pre-approve Procrit (J0885).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external transmitter for use with interstitial continuous glucose monitoring system and represented by code A9277.

You asked the Plan to pre-approve the external transmitter. You say that your current transmitter is waking you up 4 and 5 times a night. You say that your current transmitter is out of warranty and giving you incorrect readings. The Plan denied your request. The Plan says the item in dispute is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that CGM devices that do not meet the definition of a therapeutic CGM as defined in CMS Ruling 1682R will be denied as non-covered (no benefit). 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the external transmitter have not been met. Specifically, the requested supply is for use with a CGM device does not meet the definition of a therapeutic CGM.

Non-Therapeutic CGMs are not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve an external transmitter for use with interstitial continuous glucose monitoring system and represented by code A9277.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the X-ray services coded as 77081 provided on April 28, 2021.

You asked the Plan to pay for the X-ray services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim was not billed with 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 77081 has a bundled relationship with code 77080 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 X-ray services coded as 77081 provided on April 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) services coded as 70544 provided on May 28, 2021.
You asked the Plan to pay for the MRI services. You say that you would like this claim reprocessed based on the documentation submitted. The Plan denied your request. The Plan says this claim has not been billed with 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 has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 magnetic resonance imaging (MRI) services coded as 70544 provided on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular interim partial denture (D5821). 
 
You asked the Plan to pre-approve the mandibular interim partial denture. You say that you were not aware 
when you signed up for this plan that dentures were not covered. You also say that you are unable to eat 
without dentures. The Plan denied your request. The Plan says this service is not covered under your 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 pre-approve a 
mandibular interim partial denture (D5821).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure. 
 
You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says there are not enough studies on Intracept to show it 
is safe and effective. 
 
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 Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this is an experimental/investigational procedure. Therefore, the request is deemed 
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 Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99239) provided February 15, 2020.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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, the CPT Code Manual definition of code 99239 is hospital discharge day management.
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that 31 minutes or more were spent on this service. The plan requested additional documentation, and none was provided. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99239) provided February 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on June 20, 2021, billed with code 70450-26.

You asked the Plan to pay for the CT interpretation. You say that this should be paid. The Plan denied your request. The Plan says this was not billed with a proper modifier.

The Plan must follow Medicare rules. Medicare rules say that when there is an NCCI edit between two codes, only the Column 1 code is paid, unless a clinically appropriate modifier is used.

Code 70450 is a Column 2 code in relation to 70496 (Computed tomographic angiography). No clinically appropriate modifier was used to justify bypassing this edit. Therefore, we decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of the head provided on June 20, 2021, billed with code 70450-26.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care service provided on February 2, 2021.
You asked the Plan to pay for critical care. You say that you are appealing with supporting records as this critical care add-on code should have been reimbursed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because a corrected claim is needed due to incorrect coding.
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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (list separately in addition to code for primary service).
We find that CPT code 99292 is not supported in the medical record. Specifically, this code must be billed with a primary critical care evaluation and management code. Based on this information, we decided that Medicare rules for coverage of critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care service provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the phlebotomy services provided from
January 13, 2021, through March 24, 2021.
You asked the Plan to waive the copayment for the phlebotomy services. You say that you paid this on your
credit card and are disputing the cost. The Plan denied your request. The Plan says the copayments applied
correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $150
copayment for Medicare-covered, in-network, outpatient hospital services.
You have been asked to pay a total of $431.40 for the phlebotomy services.
Date of Service Service Allowed Amount Standard Copayment Member Liability
January 13, 2021 Phlebotomy $107.85 $150 $107.85
January 27, 2021 Phlebotomy $107.85 $150 $107.85
February 24, 2021 Phlebotomy $107.85 $150 $107.85
March 24, 2021 Phlebotomy $107.85 $150 $107.85
TOTAL: $431.40
The phlebotomy services fall within the "Outpatient hospital 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. Contact the Plan regarding the balance
due on these bills. Therefore, we decided that the Plan does not have to waive the copayment for the
phlebotomy services provided from January 13, 2021, through March 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the IV therapy provided on March 16, 2021.
You asked the Plan to reduce the cost for the IV therapy. You say that you always paid $40 in the past and now
they charged 20% for the infusion. The Plan denied your request. The Plan says the copayment applied
correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325
copayment for each Medicare-covered outpatient hospital visit.
You have been asked to pay $219.97, which is less than the standard $325 copayment for the IV therapy. The
IV therapy falls within the "Outpatient hospital 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 reduce the cost for the IV therapy provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on April 18, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to the emergency room and was transferred to another hospital for inpatient treatment. You say you should not be responsible for the emergency room copayment. The Plan denied your request. The Plan says 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). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency services at an in-network emergency room. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency 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 the emergency room visit provided on April 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and additional periapical x-ray (D0230) provided on June 2, 2021.
You asked the Plan to pay for the dental services. You say that you were advised the services would be covered. You say that you were not advised that you would have any x-rays done at your visit. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says periapical x-rays are not listed as covered services. The Plan also says that there is no record that you contacted them to verify benefits or provider eligibility prior to the date of service.
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 periapical x-rays are not among those covered under this benefit. Specifically, the Therefore, we decided that the Plan does not have to pay for the initial periapical x-ray (D0220) and additional periapical x-ray (D0230) provided on June 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture and infrared therapy services (97026, 97810, 97811) provided on March 3, 2021.
You asked the Plan to pay for acupuncture and infrared therapy services. You say that the patient began acupuncture treatment. Services were medically necessary and rendered based on information provided by the Plan. The Plan denied your request. The Plan says acupuncture and related services are not a covered benefit, except for chronic low back pain.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the records do not show that the services were provided for low back pain. In addition, infrared therapy is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for acupuncture and infrared therapy services (97026, 97810, 97811) provided on March 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lower limb prosthetic stance flexion feature component (code L5845).
You asked the Plan to pre-approve stance flexion feature. You say that this feature meets your unmet need of learning to walk again normally. The Plan denied your request. The Plan says the denial of authorization for this component is correct, because the record does not show why this component is needed.
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 stance flexion feature. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this request exceeds your medical needs. There is no objective clinical documentation from your treating provider or physician to support the supplier's statement that you need this prosthetic component. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stance flexion feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a lower limb prosthetic stance flexion feature component (code L5845).
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 fused to metal crown (D6061) provided on February 2, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the custom fabricated abutment and abutment supported porcelain fused to metal crown. You say that your plan accepts services rendered by this provider according to television and newspaper advertisements. You also say these services were very necessary. The Plan denied your request. The Plan says there is no coverage for OON dental services.
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, you are responsible for 100% of the cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6061) provided on February 2, 2021, by an out-of-network (OON) provider.