Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.

You asked the Plan to pre-approve Keytruda. 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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Keytruda. Our reviewer says that the medication is necessary. Our physician reviewer found this enrollee has been on pembrolizumab for recurrent disease since 2018. Recent scans with question of compression in 2 areas. If progression on a PD-1 axis inhibitor after initial response is limited to one or two sites ("oligoprogression"), local therapy to the site(s) of progression (ie, radiation, thermal ablation, or surgery) with continuation of systemic therapy with the PD-1 axis inhibitor may represent an alternative to salvage systemic therapy. Therefore, the continued use of pembrolizumab for this enrollee is reasonable and 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI scan of upper spinal canal without contrast (CPT code 72141).

You asked the Plan to pre-approve the MRI. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 physician reviewer found the clinical presentation, workup, and physical findings are suggestive of multi-joint arthritis and disc degeneration as well as carpal tunnel syndrome, not frank cervical radiculopathy. No objective evidence to support this diagnosis or another cervical condition warranting MRI was documented to justify this request. There was no planned cervical procedure. Therefore, the MRI cervical spine will be considered 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI scan of upper spinal canal without contrast (CPT code 72141).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance for vascular access provided during a procedure on December 1, 2020, billed with code 76937-59.
You asked the Plan to pay for the ultrasound guidance as billed. You say that this should be paid as it was correctly billed with the -59 modifier. The Plan denied your request. The Plan says this add-on code was not reported with an appropriate primary code.
The Plan follows Medicare rules. Medicare rules say that for code pairs with an NCCI Column 1/Column 2 relationship, the Column 2 code is only payable if reported with a modifier that is supported by the records.
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 ultrasound guidance as billed. Our reviewer says that the documentation does not support that this code should be separately paid along with code 33361. Our coding reviewer found the medical records and billing history document that procedure 33361 was also performed on December 1, 2020 and paid by the health plan. CPT 76937 is bundled with procedure 33361 but an appropriate modifier can be appended to the code, providing the medical documentation supports the appending of that modifier. The medical records provided do not include sufficient documentation to support billing 76937 with a -59 modifier representing this service being performed as a distinct or independent service from other non-E/M services performed on the same day. As such, this service cannot be verified. 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 ultrasound guidance as billed have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound guidance for vascular access provided during a procedure on December 1, 2020, billed with code 76937-59.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from January 31, 2020, through February 5, 2020.

You asked the Plan to pay for the hospital services. You say that you could not mail your claim to the Plan until you returned to America due to the COVID-19 lock down. The Plan denied your request. The Plan says the claim was filed past the 12-month timeframe.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for the hospital services was not filed until February 17, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for hospital services provided from January 31, 2020, through February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DyAnsys device.

You asked the Plan to pre-approve the DyAnsys device. You say that the enrollee has failed physical therapy,
chiropractic care, medication management, and injections. You say that the enrollee would be an excellent
candidate for the requested unit. You say that the expected benefits from the implantation are to eliminate/decrease localized and referred pain, decrease swelling, improve the clinical picture for the enrollee, and significantly increase mobility all while decreasing or eliminating the need for opioid pain medications. The Plan denied your request. The Plan says the services in dispute are not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that auricular acupuncture stimulation is non-covered by Medicare for any indication. 

We looked at the file and Medicare rules. The documentation shows that the requested DyAnsys device is an auricular peripheral nerve stimulator, which is defined as electro-acupuncture. Therefore, we decided that the Plan does not have to pre-approve a DyAnsys device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site (D4266), gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (D4241), cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) provided December 11, 2020.
You asked the Plan to pay for the guided tissue regeneration, gingival flap procedure, cone beam CT scan, and intravenous moderate sedation/analgesia. You say that these services were necessary to prevent further health issues. The Plan denied your request. The Plan says these dental services are not covered.
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. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration - resorbable barrier, per site (D4266), gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant (D4241), cone beam computed tomography (CT) image capture with limited field of view - less than one whole jaw (D0380), intravenous moderate (conscious) sedation/analgesia- first 15 minutes (D9239), and intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment (D9243) provided December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99325, 11765) provided on November 23, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that with information received from the enrollee, the claim was billed to another insurance and denied. A referral could not be obtained due to the enrollee misleading you with incorrect insurance information. 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 the domiciliary or rest home visit (99325, 11765) provided on November 23, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the application of a modality and the chiropractic manipulative treatment services received on February 8, 2021, February 9, 2021, February 11, 2021, and February 15, 2021.
You asked the Plan to pay for the application of a modality and the chiropractic manipulative treatment services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit or were billed incorrectly.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that application of modality services at issue are not manual manipulation of the spine. In addition, the chiropractic manipulative treatment services were billed incorrectly and requires a corrected claim from the non-participating provider. Therefore, we decided that the Plan does not have to pay for the application of a modality and the chiropractic manipulative treatment services received on February 8, 2021, February 9, 2021, February 11, 2021, and February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power wheelchair represented by current procedural terminology (CPT) code K0821.

You asked the Plan to pre-approve the group 2 power wheelchair. You say that the enrollee needs assistance at all times to get around. You say that the enrollee has had surgery and is weak. You say that the enrollee cannot use a walker or cane. The Plan denied your request. The Plan says there is no documentation showing that the enrollee has mobility problems that could not be sufficiently or safely resolved by the use of an appropriately fitted manual wheelchair. The Plan says that the records do not show that the enrollee does not have a caregiver who can push the enrollee in a manual wheelchair. The Plan says that there is no evaluation of the enrollee's home to see if it's able to accommodate a power wheelchair.

The Plan follows Medicare rules. Medicare rules say that power wheelchairs are covered for specific 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 the group 2 power wheelchair. Our reviewer says that the criteria for coverage have not been met.

Our physician reviewer found the enrollee has a personal mobility deficit, but it is unclear if the mobility deficit or the enrollee's dementia impairs participation in mobility related activities of daily living (MRADLs). The enrollee is dependent for MRADLs. It is not clear if the mobility deficit can be overcome with a manual wheelchair pushed by a caregiver. The documentation does not reveal that the enrollee can safely maneuver the requested wheelchair in the home given his cognitive deficits. The documentation does not support that this requested K0821 will significantly improve the enrollee's ability to participate in MRADLs in the home. 

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 group 2 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power wheelchair represented by current procedural terminology (CPT) code K0821.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and psychotherapy provided by an out-of-network provider on February 15, 2021.
You asked the Plan to pay for the office visit and psychotherapy. You say that a referral authorization is on file from your primary physician. This appeal should be approved on the same grounds as before. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not approved in advance.
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 the office visit and psychotherapy provided by an out-of-network provider on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 10 additional physical therapy visits.
You asked the Plan to provide a re-evaluation of physical therapy established plan of care (97164). You say that the enrollee needs the assistance of a skilled physical therapist in order to appropriately complete activity to maintain strength. The Plan denied your request. The Plan says there is no clinical evidence to support the medical necessity for additional physical therapy.
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 provide re-evaluation of physical therapy established plan of care (97164). 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 records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient'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 re-evaluation of physical therapy established plan of care (97164) have not been met. Therefore, we decided that the Plan does not have to provide 10 additional physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.

You asked the Plan to pre-approve a skilled nursing facility admission. You say that the enrollee would greatly
benefit from continued medical supervision and occupational therapy for continued recovery. The Plan denied
your request. The Plan says the enrollee can have the care needed at home or a different kind of facility.

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 a skilled nursing facility admission. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no
identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The beneficiary
does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of
illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 a skilled nursing facility admission have not been met. Therefore, we decided
that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing and respiratory viral testing provided on July 17, 2020 billed with codes 87801, 87500, 87150, 80307, and G0482.

You asked the Plan to pay for the testing as billed. You say that this was denied as out of network, but you have no contact with the patient before the sample is received. As such, you are not able to request authorization for out of network care. The Plan denied your request. The Plan says this was not billed with a correct POS code.

The Plan must follow Medicare rules. Medicare rules say that the reported POS code for lab claims must represent the location at which the sample was taken. POS 81 would indicate a sample taken directly by the independent lab. 

In this case, there is no evidence to support the use of POS code 81. The documentation supports that this sample was taken in the ordering provider's office and sent to the lab, which would require POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing and respiratory viral testing provided on July 17, 2020 billed with codes 87801, 87500, 87150, 80307, and G0482.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wellness exam you received on March 15, 2021.
You asked the Plan to pay for the wellness exam. You say that you changed doctors and needed to have this exam. The Plan denied your request. The Plan says only one exam is covered per year.
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 $0 copayment for one annual routine physical examination per year. Review of the file shows that you had a wellness exam on March 15, 2020. The documentation also shows that you had a covered wellness exam on March 2, 2021. This service is only covered once per benefit year. As this is the second wellness exam of the 2021 benefit year, the benefit limit has been exceeded. This means that you have been asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the Plan does not have to pay for the wellness exam you received on March 15, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve outpatient foot surgery.
You asked the Plan to pre-approve correction, hammertoe (28285). You say that you need this surgery to
relieve foot pain. The Plan denied your request. The Plan says that based on imaging results lesser forms of
treatment seem more appropriate.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 correction, hammertoe (e.g.,
interphalangeal fusion, partial or total phalangectomy) (28285). Our reviewer says that the requested fourth
digit left arthroplasty and third digit right arthroplasty are medically reasonable and necessary. Our physician
reviewer found the medical documentation supports that this injured worker is suffering with painful enlarged
bones of the fourth left toe and third right toe, hammertoes of the fourth left toe and third right toe. It is
medically reasonable for this patient to undergo arthroplasty surgery of the above-mentioned digits in order to
avoid continual chronic pain. Therefore, the requested fourth digit arthroplasty left, and third digit arthroplasty
right are medically reasonable and 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 correction, hammertoe (e.g., interphalangeal fusion, partial or total
phalangectomy) (28285) have been met. Therefore, we decided that the Plan has to pre-approve outpatient foot
surgery.
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.