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

We decided that the Plan does not have to pre-approve the chiropractic office visit you had on July 27, 2021.
You asked the Plan to pre-approve the visit. The Plan denied your request. The Plan says this is not a covered
benefit.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pre-approve the chiropractic office visit you had on July 27, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chemodenervation of a muscle provided on June 28, 2021.

You asked the Plan to waive the copayment for the chemodenervation of a muscle. You say that you disagree with how high the charges are for the procedure you received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $275 copayment for outpatient surgery and other medial services provided at hospital outpatient facilities and ambulatory surgical centers and a $0 copayment for observation stays.

The record shows that you received the chemodenervation of a muscle on June 28, 2021, at an outpatient hospital facility. The chemodenervation of a muscle is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. 

You have been asked to pay a $275 copayment for the chemodenervation of a muscle. The chemodenervation of a muscle falls within the outpatient surgery and other medial services provided at hospital outpatient facilities and ambulatory surgical centers 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 chemodenervation of a muscle provided on June 28, 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 require IRF services in order to return home at
the highest level of functional independence The Plan denied your request. The Plan says you do not meet
criteria for an IRF admission.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for shoulder surgery.
You asked the Plan to pre-approve inpatient admission. The Plan denied your request. The Plan says inpatient admission 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 inpatient admission. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient admission for right reverse total shoulder replacement 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for shoulder surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria was not met.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found in order to qualify for this monitor, you would need to be adjusting your insulin doses according to your blood glucose levels, and taking three or more insulin shots per day. You are only taking two shots, and you do not appear to be adjusting
your doses. In addition, there is no documentation as to why readings from finger sticks would not suffice 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 13, 2021.

You asked the Plan to pay for the limited oral evaluation. You say that the service should be covered. The Plan denied your request. The Plan says you have exceeded your Plan benefits for this 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for a functional electrical
stimulator.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the associated network waiver for these services does not meet the requirements for
approval, as the requested service is not authorized. 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. Additionally, you do not have a spinal cord
injury, so this request would not be covered with a network provider in any case. 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 for a functional electrical stimulator.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the introduction of needle or intracatheter services coded 36000 and the ultrasound guidance services coded 76937 provided on June 5, 2021.
You asked the Plan to pay for the introduction of needle or intracatheter services and the ultrasound guidance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 36000 and 76937 are not supported in the medical record. Specifically, code 36000 has a status indicator of "B". A status indicator of B means that payment is always bundled into payment for other services not specified and no separate payment can be made. Code 76937 is an add-on code. This code is not payable unless a listed primary procedure code is also paid. A valid primary procedure was not listed. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the introduction of needle or intracatheter services and the ultrasound guidance services have not been met. Therefore, we decided that the Plan does not have to pay for the introduction of needle or intracatheter services coded 36000 and the ultrasound guidance services coded 76937 provided on June 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) provided on July 22, 2021.
You asked the Plan to waive the copayment for the MRI. You say that the plan contract says that there is a $0 copayment for diagnostic procedures and tests. 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 $275 copayment per day, per provider for diagnostic radiology services, including magnetic resonance imaging (MRI).
You have been asked to pay $221.71, which is less than the $275 copayment for the MRI. The MRI 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 the magnetic resonance imaging (MRI) provided on July 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a hip arthroplasty.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee will likely need an inpatient stay and require cultures after this surgery due to an infection. The Plan denied your request. The Plan says they agree that the requested hip arthroplasty (27134) is medically necessary, but the procedure can be provided without an inpatient stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that a total left hip arthroplasty revision was planned to be completed with inpatient hospital admission requested. The enrollee has a past medical history of lumbosacral radiculopathy, tobacco use, hypertension, hyperlipidemia, and stroke. This procedure appears to be a planned elective procedure. The enrollee has no current infection or other acute issue documented to suggest the hospital services would likely cross two midnights for this typically ambulatory procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided with a hip arthroplasty.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 23, 2021.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 23, 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 IRF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 based upon the enrollee's current level of function, he does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee's needs can be met at a lower level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on April 14, 2021 and billed under code 76937.

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 code 76937-26-59 was billed without an appropriate primary code and not performed by the same practitioner on the same date of service. A corrected claim would be reviewed if submitted. 

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 76937 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 14, 2021 and billed under code 76937.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on August 5, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

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. 

In this case, the MUE for CPT code 67820 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 the surgical services rendered on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the computed tomography (CT) scan of the abdomen and pelvis you had on April 12, 2021, and the diagnostic colonoscopy you had on June 4, 2021, at an outpatient hospital facility.
You asked the Plan to waive the copayments for the CT scan and diagnostic colonoscopy. You say that you were not informed of these extra charges. The Plan denied your request. The Plan says you were charged these copayments 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 diagnostic radiology services and a $290 copayment for outpatient hospital services.
You have been asked to pay a $150 copayment for the CT scan and a $290 copayment for the diagnostic colonoscopy. The CT scan falls within the diagnostic radiology services benefit category and you had the diagnostic colonoscopy at an outpatient hospital facility. 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 the computed tomography (CT) scan of the abdomen and pelvis you had on April 12, 2021, and the diagnostic colonoscopy you had on June 4, 2021, at an outpatient hospital facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on June 10, 2021.
You asked the Plan to pay for the services provided. You say that the medical records support the billing. The Plan denied your request. The Plan says the documentation does not contain a signed physician order.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We looked at the file and the rules. In this case, there is no documentation showing the results of the testing would be used in the management of a specific medical problem. There are no records to show how the testing will impact clinical management of the enrollee. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on June 10, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. The Plan denied your request. The Plan says SNF
admission 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that there is no documentation showing
that the enrollee requires skilled nursing services to safely and effectively provide medically necessary and
reasonable treatment. The enrollee does not require the services on an inpatient basis, only in a skilled nursing
facility setting. Continued care in the acute inpatient rehabilitation facility is appropriate until the enrollee is
stable to transfer to a lower level of care such as home with home health services or to a long-term care facility
with part time services.
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 admission have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria was not met.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found there is a requirement for insulin use to cover this monitor. The enrollee is on once daily Lantus, and not on multiple daily doses of insulin. There is no reason stated for why needs are not being met with glucometer checks.
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 pre-approve a continuous glucose monitor for the enrollee.