Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for acute inpatient rehabilitation facility (IRF)
admission and services.
You asked the Plan to provide coverage for IRF care. You say that at the time of the appeal, IRF admission was
medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met.
We overturned the case administratively because the Plan did not submit medical record with the appeal.
The Plan requested a reopen and provided the necessary medical records.
Based on review of the medical records, the Plan is correct in this case. 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. The records show you were diagnosed with Covid pneumonia yet reported to be
medially stable. You were treated with intravenous prednisone, oxygen, and oral steroids. It should be noted
that you refused transfer to a skilled nursing facility stating you wanted to go to the IRF that your spouse had
been treated at previously. The physical therapy evaluation stated you had doubled your ambulation distance
between August 26, 2021 and August 30, 2021 and the recommendation was for home health care or continued
outpatient physical therapy. Based on the medical record 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 provide coverage
for 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 February 2,
2021 and billed under code 93000.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria were not met. We verturned the Plans denial for
insufficient claim information in the case file.
The Plan requested a reopen and provided additional claim information. The Plan provided documentation
showing that code 93280 was previously billed for the same date of service as code 93000.
The Plan is correct 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 codes and when necessary the
appropriate modifier. Code 93000 is bundled with code 93280. Per the National Correct Coding Initiatives
(NCCI) Procedure to Procedure (PTP) guidelines an edit exists between codes 93280 and 93000. This PTP edit
has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed, however, an appropriate
NCCI modifier was not billed with this PTP code edit. Procedure code 93280 was previously billed on the
same date of service and paid. Therefore, we decided that the Plan does not have to pay for physician services
provided to the enrollee on February 2, 2021 and billed under code 93000.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. 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. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific
and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and
it does not appear that the enrollee's functional level requires the unique skills of a professional therapist to
safely and effectively provide treatment, or that the services can be safely and effectively performed only by a
therapist, or under the supervision of a therapist. The enrollee should be able to transition to an independent
exercise program. The specialized skill, knowledge and judgment of a qualified therapist is not required to
establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow
further deterioration.
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 additional visits have not been met. Therefore, we decided that the Plan
does not have to pre-approve additional physical therapy visits for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for bilateral leg sclerotherapy and phlebectomy of varicose veins for the enrollee.
You asked the Plan to provide coverage for bilateral leg sclerotherapy and phlebectomy of varicose veins for the enrollee. You say that this treatment is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct LCD criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for bilateral leg sclerotherapy and phlebectomy of varicose veins. Our Physician Reviewer determined that the requested procedure on the right leg is medically reasonable. The Plan argues according to the medical records, saphenous reflux is present in enrollee's right leg and has not been successfully eliminated. The medical records show the enrollee has bilateral varicose veins. The enrollee remained symptomatic despite conservative management. A left lower extremity venous incompetence ultrasound on July 12, 2021, demonstrated that both the greater saphenous vein and the small saphenous veins were incompetent. A right lower extremity venous incompetence ultrasound on June 21, 2021demonstrated that the greater saphenous vein was incompetent.
Our Medical Director has determined that the Plan is correct in this case. The Medicare LCD L33575 states "The treatments for symptomatic varicose tributaries are either compressive sclerotherapy or micro phlebectomy. The treatments of the tributary veins will be considered medically necessary if saphenous reflux is not present or already successfully eliminated, the veins are greater than 4 mm in diameter and if the patient remains symptomatic after a six-week trial of conservative therapy." The treatment of the varicosities tributaries with sclerotherapy or phlebectomy in this case does not meet the coverage criteria, as saphenous reflux was present. Medicare coverage criteria are not met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral leg sclerotherapy and phlebectomy of varicose veins have not been met. Therefore, we decided that the Plan does not have to provide coverage for bilateral leg sclerotherapy and phlebectomy of varicose veins for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Covid-19 test provided out of the country on April 6, 2021.
You asked the Plan to pay for this testing. You say that you needed this test to return to the United States. The Plan denied your request. The Plan says testing without symptoms in a non-urgent situation outside of the country are not covered.
The Plan states testing for the purpose of travel or employment is not covered by the Plan or by Medicare. We overturned the Plans denial. The Plan requested a reopen and stated that we did not apply the correct criteria. The Plan states that the Medicare guidelines state insurers are not required to provide coverage for Covid-19 testing for surveillance or employment purposes.
The Plan is correct in this case. The Plan follows Medicare rules. The rules explicitly say that screening tests, except for the few tests listed in the Medicare rules section, are not covered. You chose to leave the country during a pandemic. Any testing required to re-enter the country is not payable by the Plan or by Medicare. This testing was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes outside of the country without symptoms or diagnostic requirement. Therefore, we decided that the Plan does not have to pay for a Covid-19 test provided out of the country on April 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on April 12, 2021.
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 Medicare billing criteria are not met. We overturned the Plans denial for insufficient information in the case file. The Plan requested a reopen and provided additional information. The Plan says that payment for this service would be included in the facility PPS payment. Payment for this service is the responsibility of the facility. All codes on this claim, or services related similarly to this procedure or surgery are denied and in addition, previous payments to these providers for this member are subject to recoupment. Medicare says "CMS does not separately pay any provider or supplier other than the facility in the prospective (PPS) payment for services furnished to the beneficiary pre-procedure in preparation for, during, or following a procedure or surgery.
The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors.
The Plan is correct in this case. The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a tissue exam (88307) provided on April 20, 2021.
You asked the Plan to pay this claim. You say that these services should be covered by the Plan. The Plan
denied your request. The Plan says these services were submitted by a student and not a physician and therefore
cannot be paid as billed. We overturned the Plans denial stating the National Provider Identifier (NPI)
Registry confirms the provider is a student in pathology but has not been updated since 2014. We stated
the Medicare records show the provider is enrolled in the Medicare program as a pathology practitioner. The
Plan requested a reopen and stated that the records clearly show the ordering provider is not a fully licensed
physician as is required for Medicare claims.
The Plan is correct in this case. While the provider is listed as a pathology practitioner, it is not confirmed that
the provider is licensed to either order or perform the tissue exam in question. Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for a tissue exam
(88307) provided on April 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for a telehealth visit on April 15,
2020 and an office visit on April 16, 2020.
You asked the Plan to waive these copayments. You say that you did not go to the office and should not be
charged. The Plan denied your request. The Plan says you had a telehealth visit on April 15, 2020 an office
visit on April 16, 2020. We partially overturned the Plans denial. The Plan requested a reopen and
provided additional information regarding the services provided.
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 $45
copayment for each specialist service, either by telehealth or in the office.
The Plan has provided records to show you had both of these services. 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
charged for a telehealth visit on April 15, 2020 and an office visit on April 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) out of network,
You asked the Plan to pre-approve an MRI out of network. You say that this MRI is medically necessary and prefer the requested out of network provider. The Plan denied your request. The Plan says while the MRI was approved, this service can be provided in network. We partially overturned the Plans denial stating the MRI was appropriate but could be provided in network. The Plan requested a reopen and stated that we actually agreed with the Plan and that the partial overturn was not correct.
The Plan is correct in this case. 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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the approved MRI. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) out of network,
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the
requested MRI. The Plan denied your request. The Plan says the requested MRI of the lumbar spine is 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 the MRI. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the enrollee has a three-year history of
low back pain. A neurological exam was normal with no documentation of abnormal reflexes or other red flag
to mandate immediate MRI without first trying a 6-week course of physical therapy. There were no plain film
results in the records. The enrollee is afebrile. Absent of any further information, the medical necessity of MRI
without a trial of physical therapy has 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 MRI have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments charged for specialist services provided on
January 4, 2021 and January 18, 2021.
You asked the Plan to waive these copayments. You say that you do not believe these copayments are correct.
The Plan denied your request. The Plan says the Plan states that this cost share was charged based on the claim
submitted by your provider and the Plan contract agreement. The Plan states you were charged $23.29 which is
less than your $25 contractual copayment per visit. We overturned the Plans denial. The Plan requested a
reopen and stated that we did not apply the correct contract language.
The Plan is correct in this case. 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 specialist service.
In this case you are being asked to pay less than your normal copayment expectation. 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 charged for specialist services provided on January 4, 2021 and January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your 
request. The Plan says the records do not show a medical condition that requires positioning of the body in 
ways not feasible with an ordinary bed in order to alleviate pain.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient:

1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or

2. Requires attachments which can only be attached to a hospital bed; AND

3. Requires frequent changes in body position and/or has an immediate need for a change in body position.

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 bed. Our reviewer says that the 
requested bed is not medically reasonable or necessary. Our physician reviewer found the documentation does 
not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed 
or why positioning of the bed in other ways is not feasible. The documentation does not support a need for 
frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary 
bed. An 11/29/21 patient appeal states that you need a hospital bed so you can have a comfortable bed to sleep 
as your current bed is too high to get in. The physician documents on 12/1/21 that you cannot lie flat and an 
appeal for the bed will be made and the physician states that they are unsure if the requested hospital bed will 
"boost your care." The criteria for the semi-electric hospital bed is not met.

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 bed have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a semi-electric hospital bed.
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 at the time of the appeal, IRF care was medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not met. We 
overturned the Plans denial. The Plan requested a reopen and provided additional information. The Plan states
that the statement put on the IRF authorization claiming that no facilities would accept the enrollee was a false
statement. The Plan states it was confirmed that a skilled nursing and rehabilitation facility accepted the
enrollee, and that the enrollee was treated at this facility from August 20, 2021 to September 13, 2021 which
was during the appeal process. The enrollee was never admitted to the IRF.
The Plan is correct in this case. 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. As the
enrollee was accepted at a SNF and chose to go the SNF, the overturn for IRF services is moot, especially since
it appears it was achieved based on false information in the prior authorization request. Medicare rules for
coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to provide coverage
for acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the 4 additional physical therapy (PT) visits.
You asked the Plan to provide coverage for 14 visits total. The Plan approved 10 visits and denied 4 visits
stating further evaluation would be needed after the 10 additional visits. We partially overturned the
denial and approved 2 visits. The Plan requested a reopen and stated that we did not apply the correct
criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say that Medicare pays for
medically necessary outpatient therapy.
The Plan is correct in that typically, an updated evaluation is required after the 10th visit to determine if there is
a need for further treatment. The Plan approved the 10 visits needed to make it to the next evaluation period.
The denial of the 4 additional visits was appropriate based on evaluation guidelines. Therefore, we decided that
the Plan does not have to provide coverage for any of the 4 additional physical therapy (PT) visits.