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

We decided that the Plan does not have to pay for analysis of an electroencephalogram (95957) and monitoring (95951).
You asked the Plan to pay for the electroencephalogram analysis and monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The CPT Code Manual definition of code 95951 is monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the electroencephalogram analysis and monitoring. Our reviewer says that CPT code 95957 does not meet criteria for billing or reimbursement consideration. Documentation for this date of service does not support that spikes are documented for analysis. Our reviewer found CPT code 95951 does not meet criteria for billing or reimbursement consideration. The documentation submitted for this date of service does not support that that monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours was performed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal valve support provided on August 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for the nasal valve support. The Plan denied your request. The Plan says that there was no authorization for this.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the nasal valve support provided on August 29, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve12 units of outpatient counseling for the enrollee.You asked the Plan to pre-approve the counseling. You say that this is medically necessary.The Plan denied your request. The Plan says there is no indication of a need for this level of care.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 counseling. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is being treated for bipolar disorder, generalized anxiety disorder, and polysubstance dependence. Based on a review of the records provided, it is noted that the enrollee has been maintaining state ability with the medication regime. The therapist is unaware of all the progress since his admission in 2011. The patient gets anxious at times and overwhelmed with difficulty expressing emotion. Based on a review of the records provided this enrollee is not require additional treatment sessions as he has shown improvement and stabilization as documented in the record. The medical plans authorization for 12 visits is inappropriate as the enrollee's stability and symptom intensity is 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 counseling have not been met.Therefore, we decided that the Plan does not have to pre-approve12 units of outpatient counseling for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for observation care (99220) provided on November 25, 2019.
You asked the Plan to pay for the observation care. You say that you would like reconsideration because this claim has been billed correctly. The Plan denied your request. The Plan says that the diagnosis is inconsistent with the procedure.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded sufficient information to verify which diagnosis code is at issue and why. We are unable to validate the Plan's denial. Therefore, we decided that the Plan has to pay for observation care (99220) provided on November 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Verio Test Strips. You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you want to use One Touch Verio Test Strips. The Plan denied your request. The Plan says there is no medical reason documented for you to have this non-preferred brand. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Your physician has not provided documentation that using the preferred brand of test strips would cause an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Verio Test Strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from June 11, 2019 through June 28, 2019.
You asked the Plan to pay for the dental services. You say that you believe this should be covered under your medical due to you having radiation. The Plan denied your request. The Plan says the services are not approved for coverage.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. This service cannot be approved. The provider is billing 41899 (unlisted code) for dental procedures which included 6 crowns, 2 root canals and 2 core build ups. There are appropriate CPT dental codes for these procedures. However, even when the provider is billing the appropriate codes, the services would not be covered. Medicare may cover some dental procedures in preparation for radiation therapy. Medicare doesn't cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices. Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you're in a hospital. Part A can pay for inpatient hospital care if you need to have emergency or complicated dental procedures, even though the dental care isn't covered. Therefore, we decided that the Plan does not have to pay for the dental services provided from June 11, 2019 through June 28, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay forthe drug testing provided on August 8, 2019.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the documentation provided does not support the diagnosed approved for testing per criteria of the LCD and LCA. The Plan follows Medicare rules. Medicare rules say that drug testing is 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 pay for the drug testing. Our reviewer says that the documentation supports that the drug testing provided was medically reasonable and necessary. Our physician reviewer found treatment for substance abuse was the intention of this testing, according to the records provided. Cocaine abuse was diagnosed. Both of these factors in context warrant drug testing to help determine the safest and most effective course of treatment. Therefore, the enrollee met criteria for the services rendered.Review of the file shows that the plan states that the LCD, L35724 and LCA, A54799 have a list of diagnosis codes that support medical necessity and any codes not present on that list, are not medically necessary. While the LCD and LCA do give a list of diagnosis codes that support medical necessity, the LCD does not state that any code notlisted is not medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing have been met.Therefore, we decided that the Plan has topay forthe drug testing provided on August 8, 2019.
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 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 IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee's functional level which is noted to be limited due to debility, occasional refusals, and non-weight bearing (NWB) status do not require orindicate that this therapy must be in an IRF with an intensive level program.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).You asked the Plan to pre-approvea CT scan of the chest. You say that the service is 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 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 service is not medically necessary. Our physician reviewer found the enrollee is noted to have chronic obstructive pulmonary disease (COPD) with frequent exacerbations. A December 2019 chest x-ray noted no lung nodules. In March 2020, a CT scan of the chest was ordered to follow-up on multiple lung nodules. The documentation does not support that the ordered CT is medically necessary or 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 a CT scan of the chest have not been met.Therefore, we decided that the Plan does not have to pre-approvea computed tomography (CT) scan of the chest (71250)
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a reduction mammaplasty 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that reduction mammaplasty is covered when specific criteria are 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 services are medically necessary. Our physician reviewer found the enrollee has signs and symptoms of symptomatic macromastia.
The plastic surgery documents note complaints of neck, back, and shoulder pain associated with the large breasts. Conservative management has included significant weight loss of 170 pounds, which did not correct her pain. Examination and review of the photographs notes severe macromastia. She has undergone conservative management with correction of obesity and continues to have functional impairment. The requested procedure meets the Medicare criteria for coverage and is reasonable and medically necessary at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve a reduction mammaplasty
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a urinary tract infection (UTI), sacral wounds and strokes. The enrollee is not intubated/ventilated. The enrollee is noted to have a poor long-term prognosis. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tremfya 100mg/ml syringe.
You asked the Plan to pre-approve Tremfya 100mg/ml syringe. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tremfya 100mg/ml syringe.
Benefits for Tremfya 100mg/ml syringe may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for an emergency department visit (99284) provided on September 26, 2019.
You asked the Plan to pay for the emergency department visit. You say that you would like reconsideration as this is not a duplicate service. The Plan denied your request. The Plan says that this service is included in another service provided at the same time by the same provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not forwarded sufficient information to identify the duplicate or paid service. There is insufficient information to verify the Plan's denial Therefore, we decided that the Plan has to pay for an emergency department visit (99284) provided on September 26, 2019.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered on December 26, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home health services under a plan of treatment.We looked at the file and Medicare rules. The file shows that the claim was not billed with the correct TOB code. 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 forthe home health services rendered on December 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies used during ambulance transport provided on November 26, 2019.You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says that this is not payable separately.The Plan must follow Medicare rules. Medicare rules say that payment under the fee schedule for ambulance services covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and does not include a separate payment for items and services furnished under the ambulance benefit.Therefore, we decided that the Plan does not have to pay for the supplies used during ambulance transport provided on November 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio for the enrollee. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is subject to step therapy. 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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary, and did not meet step therapy guidelines. Our physician reviewer found the enrollee has not trialed Remicade, Inflectra or Stelara. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Entyvio is not approved as step criteria 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 7, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documents submitted do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We find that CPT code 71045 is not supported in the record. Specifically, the documentation submitted includes records for a different date of service. There is insufficient information to corroborate the documentation and confirm that coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71045) provided on October 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips.
You asked the Plan to pre-approve Freestyle Lite test strips. You say that the enrollee already has a Freestyle
Lite meter. The Plan denied your request. The Plan says these test strips are not a preferred brand.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers
as preferred as long as the above listed conditions are met. We looked at the file and Medicare rules. The documentation does not contain a medical reason the preferred
brands cannot be used. The Plan has indicated they will approve a 90 day transition period for the requested
brand. Based on this information, we decided that Medicare rules for coverage of Freestyle Lite test strips have
not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.