Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sacroiliac joint injections (27096) and contrast material (Q9960) provided on July 9, 2020.
You asked the Plan to pay for sacroiliac joint injections and contrast material. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. The rules also say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. In this case, the MUE for CPT code 27096 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Q9960 is not supported because the use of contrast material is not documented in the submitted records. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injections and contrast material have not been met. Therefore, we decided that the Plan does not have to pay for sacroiliac joint injections (27096) and contrast material (Q9960) provided on July 9, 2020.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to hold you harmless for a medical eye exam (92014) provided on April 20, 2021.
You asked the Plan to hold you harmless for a medical eye exam. You say that you met your out-of-pocket maximum expenses for 2021 and you should not have any further expenses. The Plan denied your request. The Plan says that the copayment was applied to a service that is an additional benefit that is not covered under Original Medicare and does not apply toward the annual out-of-pocket maximum.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract says that you pay a $35 copayment for each Medicare-covered examination for diagnosis and treatment of diseases and injuries of the eye. You pay these amounts until you reach the out-of-pocket maximum. We looked at the file and the Plan's rules. The records show that you had a medical eye exam for diagnosis and treatment of the eye. The EOC confirms you pay a $35 copayment until you reach your out-of-pocket maximum. The records also show you have reached your out-of-pocket maximum. Based on this information, we decided that the Plan's rules for coverage of a medical eye exam have been met. Therefore, we decided that the Plan has to hold you harmless for a medical eye exam (92014) provided on April 20, 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the crown for tooth #20.
You asked the Plan to pre-approve the crown. You say that a piece of the crown came out and got lost. You say that you need a new crown. The Plan denied your request. The Plan says that the service is not medically necessary.
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. The Plan covers the crown when the services are medically necessary and reasonable. 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 crown. Our reviewer says that the criteria for coverage for a replacement crown for tooth #20 has been met. Our physician reviewer found that the crown in place has fractured and a significant portion of the porcelain covering the distal portion of the tooth is missing. Our physician reviewer says that the prognosis of the porcelain repair is not good, and a replacement crown is medically necessary to restore the tooth to adequate function.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-approve the crown for tooth #20.
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: 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 based on the medical records provided this
enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in
a long-term care facility on a part time basis may be appropriate in this case if the enrollee will participate.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the imaging services (70450) provided May 3, 2021.
You asked the Plan to pay for the imaging services. You say that you would like this claim reprocessed for medical necessity. 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 70450 has a bundled relationship with code 70496 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 imaging services (70450) provided May 3, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network radiology referral 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 are in-network providers 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 an out-of-network radiology referral for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 24, 2020.
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 place of service code on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 13.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes.
In this case, this claim cannot be paid as billed due to an issue with the place of service code reported. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on July 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $15 copayment charged for a physician visit provided on April 15, 2021.
You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted by your provider and your Plan contract agreement.
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 $15 copayment for each physician visit. 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 $15 copayment charged for a physician visit provided on April 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor provided to the enrollee on
April 22, 2021.
You asked the Plan to pay for the monitor. You say that this should be paid for. The Plan denied your request.
The Plan says the documentation submitted did not sufficiently document the enrollee's medical condition to
support the medical necessity for the billed supply code.
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 monitor. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is a requirement that dose adjustments be made based on blood glucose levels. There is no evidence
that this is being done. There is no evidence why the requested monitor is needed over a glucometer.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pay for a continuous glucose monitor provided to the enrollee on April 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a heating pad purchased on July 10, 2020.
You asked the Plan to pay for a heating pad. You say that a heating pad was medically necessary. The Plan
denied your request. The Plan says heating pads are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature.
This item is available to the general public and would be helpful even to those who are not sick or injured.
Therefore, we decided that the Plan does not have to pay for a heating pad purchased on July 10, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (55650) provided on February 27, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.
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 55650 is "Vesiculectomy, any approach". 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 services. Our reviewer says that the use of code 55650 is not supported by the records provided. Our reviewer found that the operative report does not describe surgical incision of the seminal vesicles. Therefore, the vesiculectomy cannot be confirmed as performed.
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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (55650) provided on February 27, 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 clinical information provided supports the need for care in an LTACH. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the records do not show that the enrollee has completed the full course in the hospital. The Plan says that the enrollee can stay in the hospital to finish treatments.

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 necessitating 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 she 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the extraction of tooth #16.
You asked the Plan to pre-approve the extraction. You say that the tooth removal has not been done but the authorization was denied. You say that the patient needs the tooth removed and the records should be corrected. The Plan denied your request. The Plan says the service was already paid for on August 18, 2021 and the extraction just needs to get completed.
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 Plan already paid for the extraction of tooth #16 on August 18, 2021 and the extraction just needs to be performed. Therefore, we decided that the Plan does not have to pre-approve the extraction of tooth #16.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (24515, 20900) provided on January 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
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 24515 is "Open treatment of humeral shaft fracture with plate/screws, with or without cerclage". The CPT Code Manual definition of code 20900 is "Bone graft, any donor area; minor or small (eg, dowel or button)".
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 services. Our reviewer says that the use of code 24515 and 20900 is not supported by the records provided. Our reviewer found that for code 24515, the operative report does no document repair of humeral shaft fracture using plate and screws to confirm this procedure has been performed. For code 20900, the operative report does not give enough detail to include retraction of fascia and muscle, and closure. Therefore, these procedures cannot be confirmed as performed. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the services (24515, 20900) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve OON services. You say that the provider will help get the enrollee's seizures under control. The Plan denied your request. The Plan says there are in-network providers 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve neurology services to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography (95861) rendered by the out-ofnetwork
(OON) provider on May 4, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the needle electromyography (95861) rendered by the out-of-network (OON) provider
on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral to nephrology 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 are in-network providers within a reasonable distance from the location that provide these 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 an out-of-network referral to nephrology for the enrollee.
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 enrollee meets the criteria for admission to an
IRF and would benefit from these services.
The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can
receive the necessary services in an alternate setting.
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 enrollee is medically stable with debility and no medical complexity and does not
require physician supervision three times per week for the ongoing management of any active or acute
exacerbations of chronic medical conditions. The enrollee has no documented rehab nursing needs, intravenous
medications or wound care needs. The enrollee is at a functional level requiring mod assistance for mobility
and requires physical and occupational therapy. While they may benefit from additional therapy, their current
level does not require an intensive, complex, multidisciplinary approach to daily therapy in an IRF.
Documentation does not support the need for a therapy program consisting of at least three hours of therapy at
least five days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation
care. The IRF admission is not medically necessary; the enrollee's therapy needs can be met in a less intensive
setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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.