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

We decided that the Plan does not have to pre-approve the transthoracic echocardiography (93306).
You asked the Plan to pre-approve the diagnostic services. You say that you are appealing the denial and the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested service is not medically necessary in the absence of any new clinical symptoms or signs.
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 diagnostic services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has a history of CAD and prior percutaneous coronary intervention of the left anterior descending artery. His left ventricular ejection fraction was normal after the procedure. He has had no intercurrent cardiac events and is asymptomatic and active without any complaints of symptoms of ischemic heart disease or heart failure. He has no history of significant valvular heart disease as well. In the absence of new signs and symptoms, repeat echocardiography would not be considered indicated 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 diagnostic services have not been met. Therefore, we decided that the Plan does not have to pre-approve the transthoracic echocardiography (93306).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an insulin pump (E0784).
You asked the Plan to pre-approve an insulin pump (E0784).. You say that their current DME is putting their health at risk. The Plan denied your request. The Plan says the documentation submitted indicates your current insulin pump is still under warranty and there is no documentation that the pump is not working correctly.
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 an insulin pump (E0784). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no indication that the enrollee's current insulin pump is not working properly, and the documentation does not support that a replacement pump 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 an insulin pump (E0784). have not been met. Specifically, the member already has an insulin pump that is under warranty. There is no medical necessity for an additional pump. Therefore, we decided that the Plan does not have to pre-approve an insulin pump (E0784).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacupuncture services (97810).You asked the Plan to pre-approvethe acupuncture services. You say that the services are medically necessary.The Plan denied your request. The Plan says acupuncture services are not covered for the enrollee's diagnosis.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the record shows no history of chronic lower back pain. The request is related to a diagnosis of Bell's Palsy.Therefore, we decided that the Plan does not have to pre-approveacupuncture services (97810).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is still being studied to determine safety and efficacy.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show the safety and efficacy of the device.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex procedure (22869).You asked the Plan to pre-approvea Vertiflex procedure. You say that the requested procedure is a medical necessity for the enrollee.The Plan denied your request. The Plan says the requested service is experimental/investigational.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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.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 Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to preYour complaint about receiving erroneous or incomplete information about coverage for the Vertiflex procedure from representatives of the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.                                                                                                                                                                                             -approvea Vertiflex procedure (22869).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary recumbent bike.
You asked the Plan to pre-approve a stationary recumbent bike. You say that this is medically necessary. The Plan denied your request. The Plan says that exercise equipment is not primary medical in nature and not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stationary recumbent bike.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 27, 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 laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the
laboratory services rendered on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fortargeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on December 18, 2020.You asked the Plan to pay forthe laboratory services. You say that the service is medically necessary.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Targeted genomic sequence analysis panel, code 81455, is non-covered by Medicare. Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the enrollee and will be denied automatically as not medically necessary.Therefore, we decided that the Plan does not have to pay fortargeted genomic sequence analysis panel (CPT code 81455) provided to the enrollee on December 18, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic CGM device (K0554) and CGM supplies (K0553).
You asked the Plan to pre-approve a CGM device and supplies. You say that you need the requested items because you can no longer prick your finger to check your levels. The Plan denied your request. The Plan says rules for a therapeutic CGM have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic CGM device (K0554) and CGM supplies (K0553).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office visit. You say that you received a letter denying your medical services with the doctor right before you scheduled appointment. You say that you did not realize the problems you would have seeing your own doctors. The Plan denied your request. The Plan says the service requested can be safely rendered in-network.
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 provide the 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-approve the office visit to be provided by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Human Papillomavirus (HPV) screening (87624) provided
on December 17, 2020.
You asked the Plan to pay for HPV screening. You say that this was not processed correctly. The Plan denied
your request. The Plan says this is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The test at issue in this appeal, HPV screening, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for
Human Papillomavirus (HPV) screening (87624) provided on December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee does not have anyone at home to watch her and she lives by herself and needs to get back to her normal self. The Plan denied your request. The Plan says an IRF admission is not medically necessary.
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. Our physician reviewer found based on the documentation provided, it is my opinion that the health Plan's denial should be upheld.
The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. skilled nursing facility, subacute rehab) 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (Current Procedural Terminology (CPT) code(s): 99213, 51798, 1036F, 99072) provided to the enrollee on February 5, 2021, by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they 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 medical services (Current Procedural Terminology (CPT) code(s): 99213, 51798, 1036F, 99072) provided to the enrollee on February 5, 2021, by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the lower extremity; without contrast material (73721) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render this service.
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 provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), of any joint of the lower extremity; without contrast material (73721) to be rendered by the out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient surgery provided to the enrollee on March 21, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the outpatient surgery. You say that payment should be made on this claim. The Plan denied your request. The Plan says that this service was available in-network.

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 outpatient surgery provided to the enrollee on
March 21, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forambulance transportation (A0425, A0427) provided on October 16, 2020.You asked the Plan to pay forambulance transportation. You say that this was denied in error because the enrollee had only one ambulance service on this date.The Plan denied your request. The Plan says this cannot be paid separately from the enrollee's inpatient stay.The Plan must follow Medicare rules. Medicare rules say that all items and nonphysician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. We looked at the file and Medicare rules. The record shows that that enrollee was an inpatient at the time that the transportation at issue was provided. This service therefore must be furnished directly by the hospital or billed through the hospital under arrangements. Based on this information, we decided thatMedicare rules for coverage of ambulance transportation have not been met.Therefore, we decided that the Plan does not have to pay forambulance transportation (A0425, A0427) provided on October 16, 2020
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nurse visits (G0299), 30 days.
You asked the Plan to pre-approve an additional 30 days of skilled visits. You say that the services are necessary. The Plan denied your request. The Plan says informal support is provided by the enrollee's family members. The Plan also says that the requested for 60 days is not medically reasonable or necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 an additional 30 days of skilled visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the enrollee does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the request for an additional 30 days of home health services are 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 an additional 30 days of skilled visits have not been met. Specifically, the enrollee has informal support available to help with instrumental activities of daily living (IADL). Therefore, we decided that the Plan does not have to pre-approve skilled nurse visits (G0299), 30 days.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81225, 81230, 81231, 81232, 81240, 81241,
81283, 81238, 81335, 81350, 81401, 81406, 81408) provided December 18, 2020.
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that when a laboratory assays two or more genes in a
patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a
single procedural service, so one CPT code must be submitted for the panel.
We looked at the file and Medicare rules. In this case, multiple CPT codes were billed for the genetic testing
panel. Unbundled codes cannot be paid. Based on this information, we decided that Medicare rules for
coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for
genetic testing (81225, 81230, 81231, 81232, 81240, 81241, 81283, 81238, 81335, 81350, 81401, 81406,
81408) provided December 18, 2020.