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

We decided that the Plan does not have to pay for the allograft (20930) provided on August 5, 2021.

You asked the Plan to pay for the allograft (20930). You say that the use of local autograft and morselized allograft are not inclusive to the posterior lumbar fusion that was performed. You say that the claim should be reprocessed and reimbursed accordingly. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

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 20930 is allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure).

We find that CPT code 20930 is not supported in the medical record. Specifically, CPT code 20930 has a status indicator of B. This means that CPT code 20930 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the allograft (20930) have not been met. Therefore, we decided that the Plan does not have to pay for the allograft (20930) provided on August 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on June 4,
2021.
You asked the Plan to waive the copayment for a specialist office visit. You say that there is a mistake on the
billing and there should not be a copayment for this service. The Plan denied your request. The Plan says the
provider billed for this service and the proper copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35
copayment for In-Network Provider and Professional Services in a Specialist's Office.
You have been asked to pay a $35 copayment for a specialist office visit. The specialist office visit falls within
the Physician/Practitioner services, including doctor's office visits 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 a specialist office visit provided on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (71045) provided on October 9, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
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 71045 is a column II code to column I code 32557. 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 the services (71045) provided on October 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are
no services available at the LTACH that the enrollee requires that are not available at the health care setting
being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic procedures and test services at
an urgent care facility provided on August 17, 2021.
You asked the Plan to waive the copayment for the diagnostic procedures and test services at an urgent care
facility. You say that you went to the facility to get a coronavirus (COVID-19) test done and did not receive
any Doctor Services. The Plan denied your request. The Plan says the provider billed for the service in an
urgent care facility and the proper copayment was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $40
copayment for Diagnostic Procedures and Tests in an Urgent Care Center.
You have been asked to pay a $40 copayment for the diagnostic procedures and test services at an urgent care
facility. The diagnostic procedures and test services at an urgent care facility falls within the Outpatient
diagnostic tests and therapeutic services and supplies 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 diagnostic procedures and test services at an urgent care facility provided on August 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary. The Plan
denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The records
show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although
orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for
the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for podiatry services provided from
September 10, 2021, to September 17, 2021.

You asked the Plan to waive the copayments for the podiatry services. You say that your toe swelled after your
first visit and you were unable to reach the provider. You say that you saw your PCP for treatment. The Plan
denied your request. The Plan says you have been charged 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 $50
copayment for each podiatry visit.

You have been asked to pay a $50 copayment for each podiatry visit, for a total of $100. The podiatry services
fall within the Podiatry Services benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for
podiatry services provided from September 10, 2021, to September 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested IRF care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your needs can be met at a lower level of care such as skilled nursing facility. 

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: Favorable

We decided that the Plan has to pre-approve Privigen.
You asked the Plan to pre-approve Privigen. You say that the enrollee's condition would qualify for an increased frequency of treatment every 3 weeks, as it wears off after 2 to 3 weeks. The Plan denied your request. The Plan says that the request is not for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Privigen. Our physician reviewer found the documentation supports that Privigen is medically reasonable and necessary for the enrollee in this case, as symptoms return after about 2 weeks. The documentation supports that Privigen is reasonably expected to be safe and effective for the enrollee 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 Privigen have been met. Therefore, we decided that the Plan has to pre-approve Privigen.
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 office visits (99214) and the health behavior assessments,
or re-assessments (96156) rendered by the out-of-network (OON) provider from March 9, 2021, through
September 13, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. 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 office visits (99214) and the health behavior assessments, or re-assessments
(96156) rendered by the out-of-network (OON) provider from March 9, 2021, through September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration because the
requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not
meet Medicare criteria for coverage of the IRF care.
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 The complexity of the member's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. There are no
complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
There is not a reasonable expectation that this member 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer device.
You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has greatly
affected his quality of daily living. The Plan denied your request. The Plan says the service is not indicated for
the enrollee's condition.
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 requested services. Our physician
reviewer found that the requested interspinous process device remains experimental. More research is needed
to show its safety and efficacy. Therefore, the requested device 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 requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous spacer device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for FoundationOne testing (81455) provided on July 23, 2021.
You asked the Plan to pay for FoundationOne testing. You say that this was medically necessary. The Plan
denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted under code
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be
denied automatically as not medically necessary.
We looked at the file and Medicare rules. The testing at issue is not considered medically necessary. Based on
this information, we decided that Medicare rules for coverage of FoundationOne testing have not been met.
Therefore, we decided that the Plan does not have to pay for FoundationOne testing (81455) provided on July
23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transfer to a different skilled nursing facility (SNF).
You asked the Plan to pre-approve transfer to a different SNF. You say that you are dissatisfied with the quality
of care being received in your current SNF. The Plan denied your request. The Plan says it is not medically
necessary to transfer to another SNF.
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 transfer to a different SNF. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found there is no indication in the provided records that the care you are presently
receiving in the skilled nursing facility is inappropriate or that you require transfer to a different facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transfer to a different SNF have not been met. Therefore, we decided that the
Plan does not have to pre-approve transfer to a different skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies and materials coded 99070 provided on March 31, 2021 and April 2, 2021.
You asked the Plan to pay for the supplies and materials. 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 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 99070 is supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). We find that CPT code 99070 is not supported in the medical record. Specifically, this code has a status code of "B". A status code of B means that payment is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the supplies and materials have not been met. Therefore, we decided that the Plan does not have to pay for the supplies and materials coded 99070 provided on March 31, 2021 and April 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where he is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmic biometry provided on September 16, 2021.
You asked the Plan to waive the copayment for the ophthalmic biometry. You say that the test is not radiological and should be fully covered. The Plan denied your request. The Plan says you have been charged 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 $30 copayment for non-radiological diagnostic services.
You have been asked to pay a $30 copayment for the ophthalmic biometry. The ophthalmic biometry falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 ophthalmic biometry provided on September 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair frame color, fold-down push handles, anti-tip tube, and crutch holder for a manual wheelchair.
You asked the Plan to pre-approve wheelchair frame color, fold-down push handles, anti-tip tube, and crutch holder. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for durable medical equipment have not been met.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The items at issue in this appeal do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve wheelchair frame color, fold-down push handles, anti-tip tube, and crutch holder for a manual wheelchair.