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

We decided that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on September 14, 2021
You asked the Plan to pay for a magnetic resonance angiography. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is 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, we have confirmed that code 70544 is a column II code to column I code 70551. 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 a magnetic resonance angiography (70544) provided on September 14, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show that it is not reasonable to expect that the patient will be able to fully benefit from the intensity of services of an IRF.
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.
The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for back pain and lower extremity weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute rehabilitation nursing needs. While you may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity 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
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).

You asked the Plan to pre-approve Entyvio. You say that Entyvio is medically necessary. The Plan denied your request. The Plan says a trial of Stelara is required before alternatives can be considered.

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 Entyvio. Our reviewer says that Entyvio is not medically necessary. Our physician reviewer found the record shows no trial of the plan preferred drug or any reason why it would be unsafe or ineffective. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio (J3380).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 24, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not billed in this case.
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 is a column II code to column I code 70496. 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 imaging services provided to the enrollee on September 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural steroid injection.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that axial neck pain is not a recommended indication for cervical epidural steroid injections.
The Plan must follow Medicare rules. Medicare rules say that epidural steroid injections can be covered if the LCD criteria have been met. 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 requested services are not considered medically reasonable and necessary in this case. You have bilateral neck and shoulder pain, but symptoms of radiculopathy are not evident. There is no neurogenic claudication mentioned. Physical therapy time frame is unclear to determine if non-invasive care standards have been met. Our physician reviewer found that your condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
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 you do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 18, 2021.

You asked the Plan to pay for the dental service. You say that you had an infection and needed your tooth extracted. You say that you felt this was an emergency and felt it need to be treated promptly. You say that the first doctor you saw was not able to do the extraction for 2 weeks. You also say that they sent you to a different doctor. The Plan denied your request. The Plan says 1 limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has been exceeded.

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 and limited oral evaluation is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on May 10, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on May 18, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest.
You asked the Plan to pre-approve a CT scan of the chest. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the chest. Our reviewer says that the services are medically necessary. Our physician reviewer found since there was a documented change in the fluorodeoxyglucose uptake in the left apex seen when comparing the most recent positron emission tomography scan to the prior scan of February 10, 2021 it is reasonable to perform the CT as a surveillance study no matter what the staging is. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT scan of the chest have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the chest.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided on June 11, 2021 and billed with DRG (diagnosis related group) 286.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support complications.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 286, circulatory disorders except acute myocardial infraction, with cardiac catherization with major complications or comorbidities. 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 inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the enrollee was diagnosed with acute on chronic diastolic heart failure, but the ejection fraction (EF) was estimated at 65%. She responded to initial conservative treatments, underwent no stenting or other invasive procedures and was stable overnight. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided on June 11, 2021 and billed with DRG (diagnosis related group) 286.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for duplex scan of extremity veins (93971) provided on July 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the diagnostic service. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 duplex scan of extremity veins (93971) provided on July 28, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the rental of a portable oxygen concentrator (E1392) provided on April 15 to July 15, 2021.
You asked the Plan to waive the coinsurance for the rental of a portable oxygen concentrator. You say that you did not have physical possession of the item at issue from April through July of 2021 while the item was being repaired. The Plan denied your request. The Plan says the correct coinsurance 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 20% coinsurance for Medicare-covered durable medical equipment and supplies. You have been asked to pay $15 per month, or 20% of the Medicare-allowed charge per month of $75, for the rental of a portable oxygen concentrator.
A portable oxygen concentrator falls within the "Durable medical equipment (DME) and related 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 coinsurance for the rental of a portable oxygen concentrator (E1392) provided on April 15 to July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on June 3, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim is not payable based on the Integrated Outpatient Code Editor (I/OCE).
The Plan must follow Medicare rules. Medicare rules say that code 38205 has a Status Indicator of B and is not recognized under the Outpatient Prospective Payment System. Medicare rules state that a code with Status Indicator B results in an I/OCE edit of 62, meaning that the whole claim will be rejected and returned to the provider until the error is corrected. We looked at the file and Medicare rules. Code 38205 has a Status Indicator of B and is not payable. We reviewed the I/OCE Specifications file for this date of service. OCE Edit 62 is invoked when a code has a Status Indicator of B. The required disposition for a claim with this edit is Return To Provider. This means the whole claim is returned to the provider. The provider can resubmit the claim once the problem is corrected. Based on this information, we decided that Medicare rules for coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on June 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture each additional 15 minutes (97811) medical nutrition therapy (97803) infrared light therapy (97026)
You asked the Plan to pay for the acupuncture services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee is not being treated for chronic low back pain. The records do not support medical nutritional therapy services were provided. Infrared therapy is not a covered service.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, [ADJUDICATOR ENTER CASE SPECIFICS]. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture each additional 15 minutes (97811) medical nutrition therapy (97803) infrared light therapy (97026)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for EEG monitoring provided on May 24, 2021.
You asked the Plan to pay for EEG monitoring. The Plan denied your request. The Plan says EEG monitoring was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that ambulatory EEG can be utilized in the differential diagnosis of syncope and transient ischemic attacks if not elucidated by conventional studies. Ambulatory EEG should always be preceded by a resting EEG. 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 EEG monitoring. Our reviewer says that EEG monitoring does not meet the Medicare coverage criteria. Our physician reviewer found that the enrollee
is a 73-year-old female with lumbar spinal hardware removal and spinal fusion decompression surgery. EEG monitoring was performed during the surgery on May 24, 2021. No significant changes were noted throughout the surgical procedure. There are no formal NCD criteria for EEG monitoring in the setting of spinal surgery. However, upon review of the available literature, there is limited supportive evidence and insufficient high-quality evidence to show this testing leads to improved outcomes for this clinical situation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of EEG monitoring have not been met. Therefore, we decided that the Plan does not have to pay for EEG monitoring provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided December 30, 2020.
You asked the Plan to pay for the acupuncture services. You say that please review. Attached are medical records for this date of service. The Plan denied your request. The Plan says the provider is not a non-covered provider type.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the rendering provider is a licensed acupuncturist, not a physician. The provider is not a licensed physician per Medicare and the EOC requirement. The person providing the acupuncture must be a physician licensed to perform the service. Therefore, we decided that the Plan does not have to pay for acupuncture, initial 15 minutes (97810) acupuncture, each additional 15 minutes (97811) provided December 30, 2020.