Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

e decided that the Plan does not have to pre-approvespeech therapy.You asked the Plan to pre-approvespeech therapy. You say that the services are necessary.The Plandenied 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 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 speech therapy. 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 based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition as provided records document that the enrollee is showing no signs of carryover outside of therapy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of speech therapy have not been met.Therefore, we decided that the Plan does not have to pre-approvespeech therapy.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on April 21, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on April 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefacet joint injections.

You asked the Plan to pre-approvefacet joint injections. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are only covered for certain indications.

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 facet joint injections. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has low back pain. The enrollee's pain is axial in nature. An MRI showed multilevel degenerative changes, compression deformities, and facet arthropathy. The documentation submitted and reviewed shows that the enrollee has multiple compression fractures of which there is no indication of having been ruled out or evaluated as a source of the pain. The review has determined that the enrollee does not have a diagnosis, condition, and/or symptoms that meet the Medicare criteria for coverage of facet joint injections

.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approvefacet joint injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 and MTHFR gene analysis for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says these tests are not considered efficacious.
The Plan must follow Medicare rules. The rules say that F5 and MTHFR testing is not considered to be clinically efficacious. The requested testing is not considered medically necessary by Medicare. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F5 and MTHFR gene analysis for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for a diagnostic colonoscopy provided.

You asked the Plan to waive the co payment for a diagnostic colonoscopy. You say that this shouldn't be considered diagnostic just because a few polyps were removed. The Plan denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 co payment for outpatient surgery/in-network/hospital. 

You have been asked to pay a $200 co payment for a diagnostic colonoscopy. Evidence was provided to show that polyps were removed. The rules say that, if during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed.A diagnostic colonoscopy falls within the outpatient surgery/in-network/hospital 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 a diagnostic colonoscopy provided by a participating provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approverevascularization (37221).You asked the Plan to pre-approverevascularization. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 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 pre-approve revascularization. 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 you have atypical leg symptoms much of which does not sound like claudication, reference to anterior tibial occlusion that is not quantified, no trial of compression socks and most importantly ankle-brachial indexes (ABIs) that are not reduced.  In this circumstance the records do not support the medical necessity for lower extremity revascularization.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of revascularization have not been met.Therefore, we decided that the Plan does not have to pre-approverevascularization (37221).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on November 6, 2019 billed with code 27507.
You asked the Plan to pay for the services as billed. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says plate/screws for fixation of a femoral fracture were not documented.
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 27507 is Open treatment of femoral shaft fracture with plate/screws, with or without cerclage. We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services as billed. Our reviewer says that the records do not support the billing of this code. Our coding reviewer found the operative report does not include enough documentation to confirm that plate/screws were used to perform open treatment of femoral shaft fracture. As such, this code cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on November 6, 2019 billed with code 27507.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assistant surgeon services provided on February 26, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this type of provider is not payable for assistant surgeon services.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears thedesignation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay forthe assistant surgeon services provided on February 26, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea lung cancer screening with low dose computed tomography (LDCT).

You asked the Plan to pre-approvethese 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 LDCT for lung cancer screening is covered for asymptomatic patients that meet specific criteria.

We looked at the file and Medicare rules. The records show that the enrollee has a lung mass and is therefore not asymptomatic. 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-approvea lung cancer screening with low dose computed tomography (LDCT).
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forout of area (OOA) services provided.

You asked the Plan to pay forthe OOA services. You say that the enrollee was visiting relatives out of area when she required emergency care. You say that the enrollee had not yet returned to the service area and had continued health issues that required the treatment in dispute.The Plan denied your request. The Plan says that the enrollee was not authorized for the services in dispute. The Plan says that the enrollee was not referred by their primary care physician for the services. The Plan says that no urgent or emergency situation has been documented.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the OOA services. Our reviewer says that the criteria for OOA coverage have been met.Our physician reviewer found the enrollee received reasonable and necessary care while out of area. The initial care was emergent, and the follow-up care was appropriate and necessary. The enrollee could not have foreseen requiring the services prior to leaving the service area. Our physician reviewer found that the documentation supports the medical necessity of the services and that a delay in the enrollee's care until a return to the service area would not have been reasonable.

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 OOA services have been met.Therefore, we decided that the Plan has to pay forout of area (OOA) services provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint intervention.
You asked the Plan to pre-approve facet joint intervention. You say that the requested facet joint intervention is
medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the
requested facet joint intervention.
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 facet joint intervention. Our reviewer
says that the enrollee does not meet criteria for the requested facet joint intervention. Our physician reviewer
found the enrollee is with history of arthritis, migraines, current smoker, seizures, ADD, depression,
fibromyalgia, and chronic pain syndrome. She has 7/10 mid to lower back pain. The pain is worse with
bending, walking, and standing for long periods of time. She is maintained on Suboxone and Gabapentin for
pain control. The enrollee has received previous injection therapy. Her provider has requested additional facet
injections.
In this case, there is no documentation of a failure to respond to conservative care such as nonsteroidal antiinflammatory
drugs (NSAIDS), acetaminophen, physical therapy for a minimum of 6 weeks (as tolerated). In
addition, there was no documentation that there had been a positive response of at least 80% relief of primary
(index) pain (with the duration of relief being consistent with the agent used) or at least 50% improvement in
the ability to perform previously painful movements and activities of daily living from the previous injection.
The review has determined that the enrollee does not meet the above LCD criteria for the requested facet joint
intervention.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of facet joint intervention have not been met. Therefore, we decided that the Plan
does not have to pre-approve facet joint intervention.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetransurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) (CPT Code 0421T).You asked the Plan to pre-approvethe services. You say that you are having painful urination for quite some time and feel this procedure is a safer one.The Plan denied your request. The Plan says medical studies haven't proven that the service(s) or procedure(s) is helpful for treatment of your health problem.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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary inthis case. Our physician reviewer found the 2020 AUA Guidelines for BPH state: Aquablation may be offered to patients with lower urinary tract symptoms (LUTS) attributed to Benign prostatic hyperplasia (BPH) provided prostate volume great than 30 and lessthan 80g. The medical records provided do not include the prostate volume.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approvetransurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed) (CPT Code 0421T).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forprivigen(J1459) provided on January 27, 2020.You asked the Plan to pay forprivigen. You say that the item is medically necessary.The Plan denied your request. The Plan says FDA approved drugs used for indications other than what is indicated on the official label may be covered if the use is determined to be medically accepted, taking into consideration  the  major  drug  compendia,  authoritative  medical  literature  and/or  accepted  standards  of  medical  practice.  The administered privigen does not meet this criterion and therefore, remains denied.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 privigen. Our reviewer says that the item is not medically necessary. Our physician reviewer found privigen is not FDA approved for the above diagnoses, the approved compendia, does not support the use of Privigen for any of the member's diagnoses.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of privigen have not been met.Therefore, we decided that the Plan does not have to pay forprivigen (J1459) provided on January 27, 2020.Benefits for privigenmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to waive the copayment for an x-ray provided by a participating provider on June 23, 2020.
You asked the Plan to waive the copayment for an x-ray. You say that you paid your copayment. You say that you are not sure why you are being charged again. The Plan denied your request. The Plan says the correct copayment has been 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 a $35 copayment for outpatient diagnostic tests/x-ray. You have been asked to pay $34.20 which is less than your copayment amount of $35 for an x-ray. When additional services are provided during an office visit, additional copayments can be applied; therefore, the correct copayment has been applied. An x-ray falls within the outpatient diagnostic tests/x-ray 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 an x-ray provided by a participating provider on June 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral for proton beam radiation therapy with an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plan denied your request. The Plan says appropriate care is available in plan.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 providethe items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea referral for proton beam radiation therapy with an out-of-network provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory tests provided on June 8, 2020.
You asked the Plan to waive the copayment for laboratory tests. You say that you did not know you would owe
a copayment for labs provided at an outpatient hospital facility 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 $15
copayment for lab services provided at an outpatient hospital facility.
You have been asked to pay a $15 copayment for laboratory tests. Laboratory tests fall 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 laboratory tests provided on June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection.
You asked the Plan to pre-approve a lumbar epidural injection. You say that the requested lumbar epidural injection is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested lumbar epidural injection.
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 a lumbar epidural injection. Our reviewer says that the enrollee does not meet criteria for the requested lumbar epidural injection. Our physician reviewer found the review indicates that the enrollee is with history of chronic low back pain with radiculopathy, thoracic spondylosis, complex regional pain syndrome of the right lower limb, sacroilitis and postlaminectomy syndrome. The enrollee's pain has been treated with medical therapy including opiates, facet injections, lumbar transforaminal injections, and epidural steroid injections. His provider has requested a right L5 and/or S1 and/or S2 steroid injections. The review indicates that no more than two foramina may be injected on the same day. Documentation submitted provided no additional information that justifies this request. The review has determined that the enrollee does not have a covered indication per the above LCD for the requested epidural injections. 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 lumbar epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection.