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

We decided that the Plan does not have to pay for nerve conduction studies (95912) with needle
electromyography (95885) provided on April 17, 2021.
You asked the Plan to pay for nerve conduction studies with needle electromyography. You say that you have
provided supporting records for the CPT codes at issue. The Plan denied your request. The Plan says the codes
at issue are not appropriate for 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 95912 is "Nerve conduction studies; 11-12 studies."
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 nerve conduction studies with needle electromyography. Our
reviewer says that the codes at issue do not meet criteria for payment. Our reviewer found that with regard to
CPT code 95912 the procedure report describes Pedicle Testing, which is not nerve conduction studies which
measures amplitude, latency/velocity, and therefore the billed procedure cannot be verified. Nerve conduction
procedures codes should not be reported for pedicle stimulation. As for CPT code 95885, this procedure is
"done with nerve conduction, amplitude and latency/velocity study." In this case, a nerve conduction study was
not verified and therefore the related procedure would not be covered.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of nerve conduction studies have not been met. We have also confirmed that code
95885 is an add-on code and that an appropriate primary procedure code cannot be verified. Based on the claim
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to
pay for nerve conduction studies (95912) with needle electromyography (95885) provided on April 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says this is 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 the injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that in this case, although there was short-term pain relief, a few weeks post-injection, there was no
record of residual benefit on 12/2/2021 following the 10/27/2021 epidural steroid injection. There was no
record of sustained improvements in pain or function lasting at least 3 months. The guidelines for coverage of
62323 are not met. The procedure 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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a repeat epidural steroid injection for the enrollee
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta extended-release knee injections.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not medically necessary for painful joint inflammation of the knee.
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 the injections. Our reviewer says that
the requested injections are not medically reasonable or necessary. Our physician reviewer found based on the
medical records provided, and the Medicare-approved major drug compendia there is no documentation
that the repeat Zilretta injection meets Medicare criteria for medically reasonable and necessary for the
enrollee. The safety and efficacy of repeat administration of Zilretta have not been established. 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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve Zilretta extended-release knee injections.
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory work provided on September 13, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for laboratory work provided on September 13, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that you have trouble eating and need to continue 
with improving strength and mobility. You say that you have come so far and cannot now go home. You say 
that you need to stay at the SNF for continued physical therapy. The Plan denied your request. The Plan says 
the continuation of SNF care 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there are no skilled nursing service needs 
identified. The documentation does not support that the enrollee in this case requires skilled therapy services. 
The enrollee appears to be at a custodial level of care. The enrollee does not require necessary services on an 
inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left shoulder. 
 
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 MRIs are covered only when they are medically 
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 left shoulder pain. The 
physical examination revealed Speed's, positive tenderness at left shoulder, positive Neer's left shoulder, 
positive Hawkins left shoulder, and left shoulder joint tenderness. There is no documentation of a left shoulder 
x-ray or physical findings of a red flag diagnosis that would warrant bypassing basic imaging. 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 magnetic resonance imaging (MRI) of the left shoulder.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from January 31, 2022, forward.

You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that inpatient psychiatric care remains medically necessary. The Plan denied your request. The Plan says this care was no longer medically reasonable and necessary.

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 the continuation of inpatient psychiatric care. Our reviewer says that the requested inpatient psychiatric care is not medically reasonable and necessary. Our physician reviewer found that based upon review of the records provided it was not expected this enrollee would improve in a reasonable period of time as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he did not have dangerousness to self or others, perceptual disturbance including delusions, auditory or visual hallucinations. 

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 continuation of inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from January 31, 2022, forward.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer (J1439).

You asked the Plan to pre-approve Injectafer. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says step therapy criteria have not been met.

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 Injectafer. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the patient is a 76 year old female with iron-deficiency anemia related to recent gastrointestinal bleed from stomach ulcer. In this case, the documentation does not clearly show that the patient has tried and failed the Plan's preferred drugs Infed or Venofer. In addition, Infed or Venofer would not likely be less effective and/or likely have more adverse side effects for the enrollee as they are clinically equivalent compared to each other and compared to Injectafer as comparison studies show similar risk and benefit profiles. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay this claim as billed.

You asked the Plan to pay for these services.. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says code 77003-59 was billed without an appropriate primary code and was not shown to be performed by the same practitioner on the same date of service.

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 inconsistencies with the codes billed and the providers listed as having performed the service. Therefore, we decided that the Plan does not have to pay for physician services billed to the enrollee for May 18, 2021 under code 77003.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit (99204) and an ophthalmic diagnostic imaging (92134) provided on August 17, 2021.

You asked the Plan to waive the copayment for an office visit and an ophthalmic diagnostic imaging. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $25 copayment for each Medicare-covered exam to treat an eye condition. Your contract with the Plan also clearly says that you must pay a $55 copayment for vision care and outpatient diagnostic tests and therapeutic services and supplies. 

You have been asked to pay a total copayment of $55 for an office visit and an ophthalmic diagnostic imaging. The EOC confirms that $25 is the required copayment for an office visit to treat an eye condition. The EOC also confirms that you pay up to a $55 copayment for each ophthalmic diagnostic imaging. You have been asked to pay a copayment of $30 for the diagnostic imaging, which is less than the Plan's contracted amount. Your total cost share is $55 ($25 + $30 = $55). 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 an office visit (99204) and an ophthalmic diagnostic imaging (92134) provided on August 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for extractions (D7210 x2), removal of residual tooth roots
(D7250), therapeutic, prophylactic, or diagnostic injection (96374), and anesthesia (00170) provided on August
25, 2020.
You asked the Plan to pay for extractions, removal of residual tooth roots, therapeutic, prophylactic, or
diagnostic injection, and anesthesia. You say that you were not aware the services at issue would not be
covered. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for extractions (D7210 x2), removal of residual tooth roots (D7250), therapeutic, prophylactic, or diagnostic injection (96374), and anesthesia (00170) provided on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 9, 2021.

You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for this testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided there is no documentation that the SelectMDx test provided to the enrollee on June 9, 2021 at issue in this case meets Medicare criteria for medically reasonable and necessary.

No patient-specific information documenting necessity of the testing was provided. There is no documentation in the records available to this reviewer that the test was reasonable and necessary for this specific patient for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member as required by Medicare guideline. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 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 you are improving but still require high flow oxygen and ongoing acute care services. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH 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 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
June 11, 2021, by an OON provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that the rendering physician is a 
Hospitalist physician with the group and depends upon the hospital staff to verify eligibility and to obtain the 
proper authorization from the enrollee's insurance company. You also say that the treating provider rendered 
medically necessary services to the enrollee in good faith. The Plan denied your request. The Plan says the 
service provided requires prior authorization. The Plan also says that no authorization has been obtained. 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 subsequent nursing facility care (99308) 
provided on June 11, 2021, by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
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 that the enrollee continues to receive acute care services, and these have not been 
denied. The medical record does not indicate that the enrollee requires services that she is not currently 
receiving but that would be available at the LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.