Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services for the surgery provided on March 4, 2021.

You asked the Plan to pay for the surgical assistant services for the tendon sheath incision (26055). You say that the records document medical necessity needs for a surgical assistant. The Plan denied your request. The Plan says services of an assistant surgeon are not covered for this procedure.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 26055. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services for the tendon sheath incision (26055) have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services for the surgery provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for multianalyte assays with algorithmic analyses, pathology test services (0012M) provided February 4, 2021.

You asked the Plan to pay for the pathology test services. You say that the codes for CxBladder (0012M and 0013M) will be eligible for payment as long as the service meets the medical necessity guidelines and the medical records state the need for the service. The Plan denied your request. The Plan says the pathology test is considered experimental and/or investigational.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pathology test services have not been met. Therefore, we decided that the Plan does not have to pay for multianalyte assays with algorithmic analyses, pathology test services (0012M) provided February 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on September 14, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. 
The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out of network (OON) provider on
September 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance tablets.

You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this drug is not covered by Medicare Part B.

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 Jardiance tablets.

Benefits for self-administered drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out of network (OON) provider on December 23, 2020.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.

We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (88305) rendered by the out of network (OON) provider on December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services needed, in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COPD and respiratory arrest. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs.

The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of medial branch block for the enrollee.

You asked the Plan to pre-approve the blocks. You say that this is medically necessary. The Plan denied your request. The Plan says a third level is not allowed.

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 blocks. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no medical rationale for the third level that's been requested. The LCD limits the diagnostic blocks to two levels at one session. Therefore, the request for the third level is deemed not medically reasonable or 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 blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of medial branch block for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services received from February 6, 2020 to August 24, 2020.

You asked the Plan to pay for the services. You say that this should be approved. The Plan denied your request.
The Plan says a corrected claim is not needed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate detailed diagnosis code.

F43.1 is not the most appropriate diagnosis code to use in this case, as it not detailed enough. 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 pay for outpatient mental health services received from February 6, 2020
to August 24, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab 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 this treatment is only used if certain markers are not found in the cancer cells using special testing.

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 the drug. Our reviewer says that the requested drug regimen is not medically reasonable or necessary. Our physician reviewer found FDA approval for pembrolizumab is for first-line treatment (in combination with pemetrexed and platinum chemotherapy) of metastatic nonsquamous NSCLC in patients with no EGFR or ALK genomic tumor aberrations. There are no ALK or EGFR results. Tissue is reported as insufficient for testing. However, this would be an indication for liquid NGS. The service is not reasonable or 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 have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, and Pembrolizumab for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on June 9, 2020, by an out of network provider.

You asked the Plan to pay for psychotherapy services. You say that the services at issue were a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 psychotherapy services provided on June 9, 2020, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone medical discussion with physician (99442) provided on January 5, 2021, by an out of network (OON) provider.

You asked the Plan to pay for the telephone medical discussion with physician. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 telephone medical discussion with physician (99442) provided on January 5, 2021, 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 office visit (99202) and the chiropractic manipulative treatments (98940) rendered by the out of network (OON) provider from February 10, 2021, through March 12, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99202) and the chiropractic manipulative treatments (98940) rendered by the out of network (OON) provider from February 10, 2021, through March 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the in-home infusion of Gamunex-C for the enrollee.

You asked the Plan to pre-approve the in-home infusion of Gamunex-C. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that chronic inflammatory demyelinating polyneuropathy (CIDP) is not a covered diagnosis for treatment of in-home IVIG infusion therapy under part B benefits.

The Plan must follow Medicare rules. Medicare rules say that to be covered under B, immune globulin can be delivered via IV in the home for primary immune deficiency or subcutaneously through a pump for CIPD but only if it's been shown to be effective. 

We looked at the file and Medicare rules. In this case, the enrollee does not have primary immune deficiency and it is not documented that this is to be delivered subcutaneously or that the patient has previously responded to this treatment. Based on this information, we decided that Medicare rules for coverage of the in-home infusion of Gamunex-C have not been met. Therefore, we decided that the Plan does not have to pre-approve the in-home infusion of Gamunex-C for the enrollee.

Benefits for the in-home infusion of Gamunex-C 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 25, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 25, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia Sol syringes to be provided by a pharmacy.

You asked the Plan to pre-approve Prolia syringes. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because coverage of this drug falls within Medicare Part D and is not covered under Medicare Part B.

The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 

In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia Sol syringes to be provided by a pharmacy.

Benefits for Prolia syringes 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).

You asked the Plan to pre-approve a power operated vehicle. You say that the requested item is a necessity for
your care. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested item is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 power operated vehicle.

Our reviewer says that the requested item is not medically necessary. Our physician reviewer found that the
documentation does not support that you have a mobility limitation that significantly impairs your ability to
participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing,
grooming, and bathing in customary locations in the home. The documentation does not reveal that your
mobility limitation cannot be sufficiently and safely resolved by the use of an appropriate walker or manual
wheelchair. The documentation does not reveal that your home provides adequate access for the requested
scooter and that the use of the scooter will significantly improve your mobility-related activities of daily living.

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 power operated vehicle have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Group 1 standard power operated vehicle (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the manual manipulation or pay for the spine x-rays provided on March 4, 2021.

You asked the Plan to waive the coinsurance for the manual manipulation treatment (98941) and pay for the spine x-rays (72082). You say that you would like the Plan to pay this claim The Plan denied your request. The Plan says the x-ray services are not covered and the manual manipulation has a 50% coinsurance.

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 the service at issue, the x-rays, are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to waive the coinsurance for the manual manipulation or pay for the spine x-rays provided on March 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the panoramic radiographic image (D0330), comprehensive periodontal evaluation (D0180), bone replacement graft - retained natural tooth - first site (D4263), guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal implant (D6010), and extraction, erupted tooth or exposed root (D7140) provided February 1, 2021, and February 8, 2021.

You asked the Plan to provide additional payment for the panoramic x-ray, comprehensive periodontal exam, bone replacement graft, guided tissue regeneration, endosteal implant, and tooth extraction. You say that the Plan's information about coverage is misleading. The Plan denied your request. The Plan says the claims have processed correctly.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan reimburses panoramic x-rays, comprehensive periodontal exams, and tooth extractions provided out-of-network based on the rate established by the Plan.

We looked at this physician's review, the file, and Medicare rules. In this case the Plan has provided reimbursement for the panoramic x-rays, comprehensive periodontal exam and endosteal implant provided out-of-network in accordance with the rate established by the Plan. Based on this information, we decided that the Plan does not have to provide additional reimbursement for the panoramic x-rays, comprehensive periodontal exam, and tooth extraction provided February 1, 2021, and February 8, 2021 by an out-of-network provider. Though the Plan offers dental benefits in excess of Medicare coverage, the bone replacement graft, guided tissue regeneration and endosteal implant are not among those services covered by the Plan. Therefore, we decided that the Plan does not have to pay for the bone replacement graft - retained natural tooth - first site (D4263), guided tissue regeneration - resorbable barrier, per site (D4266), or surgical placement of implant body: endosteal implant (D6010) provided February 8, 2021.