Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health/hospice aide in home health or hospice
settings, each 15 minutes, (G0156) for 14 hours per week.
You asked the Plan to pre-approve home health aide services. You say that the enrollee is confined to their
home. You also say that the enrollee would benefit from skilled services. The Plan denied your request. The
Plan says the enrollee seems to be independent with activities of daily living and has not identified skilled
needs. The Plan also says that the requested home health aide services are 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 home health aide services. Our
reviewer says that the home health aide services are not medically necessary. Our physician reviewer found the
provided documentation does not indicate that the enrollee has skilled nursing needs. Therefore, the reviewer
found that the home health aide 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 home health aide services have not been met. Therefore, we decided that the
Plan does not have to pre-approve home health/hospice aide in home health or hospice settings, each 15
minutes, (G0156) for 14 hours per week.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cone beam computed tomography (CT) capture and
interpretation with field of view of both jaws, with or without cranium (D0367).
You asked the Plan to pre-approve a cone beam CT scan. You say that this service is necessary for a dental
implant to be installed properly. The Plan denied your request. The Plan says this service is not covered under
your dental benefits.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
cone beam computed tomography (CT) capture and interpretation with field of view of both jaws, with or
without cranium (D0367).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and extractions (D7210) for tooth #22 and tooth #27.

You asked the Plan to pre-approve the denture and extractions. You say that you previously had a lower denture which was supported by two teeth. One broke, and both teeth needed to be extracted and the denture re-fitted. You say that you did not previously have upper dentures but need them now. The Plan denied your request. The Plan says the requested services exceed the benefit's limitations. The Plan can cover one denture every 5 years per jaw, and the Plan previously paid for a complete upper denture for you in February 2020. The Plan also limits extractions to once per tooth per lifetime. You already had these teeth removed in April of 2021.

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 can cover one complete upper denture every 5 plan years. The Plan can also cover one extraction per tooth per lifetime. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the items or services are requested in a frequency that is not covered under this benefit. Documentation shows that the Plan paid for a complete upper denture in February 2020 and that the teeth requested for extraction have already been extracted. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and extractions (D7210) for tooth #22 and tooth #27.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a quantitative calcium scoring procedure (75571).
You asked the Plan to pre-approve a quantitative calcium scoring procedure. You say that the requested service is medically necessary for your condition. The Plan denied your request. The Plan says this service is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered service. We looked at the file and Medicare rules. The request is for a service not covered by Medicare or the Plan. Based on this information, we decided that Medicare rules for coverage of a quantitative calcium scoring procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a quantitative calcium scoring procedure (75571).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve emergency alert system.

You asked the Plan to pre-approve emergency alert system. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit under Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that emergency alert systems are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of emergency alert system have not been met. Therefore, we decided that the Plan does not have to pre-approve emergency alert system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 13, 2020.

You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered.The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. 

We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met.

Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. 

Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met.Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on October 13, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a laparoscopic cholecystectomy (47562).
You asked the Plan to pre-approve a laparoscopic cholecystectomy. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for a laparoscopic cholecystectomy have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a laparoscopic cholecystectomy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the record indicates the enrollee has had an ultrasound that demonstrates cholelithiasis without evidence of cholecystitis. At the emergency room the laboratory tests were normal except a mildly elevated alkaline phosphatase. The associated symptoms have been relieved by Pepcid. No hepatobiliary iminodiacetic acid (HIDA) scan has been performed. The provided documentation does not support the medical necessity and reasonableness of the requested service as defined by Medicare rules.
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 laparoscopic cholecystectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a laparoscopic cholecystectomy (47562).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you ask the Plan to review the enclosed documentation to support medical necessity of the prescribed PCD in treating the enrollee's lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and pneumatic appliance (E0667).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 4, 2021.
You asked the Plan to pay for the services. You say that you also bill Medicare, who allows these claims. The Plan denied your request. The Plan says procedures reported together must be both medically reasonable and necessary and ordered by the physician who is treating the beneficiary.
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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee underwent pharmacogenetic panel testing after having a negative urine drug screening. The submitted records are insufficient to support the testing provided.
The requested service is not medically reasonable and necessary as defined by Medicare rules. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on January 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp injection until discontinued.
You asked the Plan to pre-approve Aranesp; injection, darbepoetin alfa, 1 microgram (non-esrd use) (J0881). You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says they will approve a portion of the request.
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 Aranesp; injection, darbepoetin alfa, 1 microgram (non-esrd use) (J0881). Our reviewer says that the drug is not medically necessary. Our physician reviewer found based on the medical records provided the patient has not tried and failed the required drugs. Based on the medical records provided there is no indication that the plan's required drug would likely be less effective and/or likely have adverse effects for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp; injection, for indefinite use have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp injection until discontinued.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on August 24, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression
or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is
application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The
HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals).
The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection
(specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code
J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection,
thiamine HCl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine HCl,
100 mg.
We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record.
Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer
of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the
criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was
applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code
97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed.
The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy
at the same time; the criteria for reporting CPT code 97150 has not been met.
Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record
does not contain documentation of the dosage and type of drug administered in each injection, which is
required by Medicare for these services to be reimbursed.
Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections
and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to
pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 24, 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.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary or reasonable.
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 the patient does not require treatment by multiple therapies and there are no complex nursing or rehabilitation 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 IRF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent 15 minutes of moderation sedation services provided on December 3, 2020, billed with code 99153.
You asked the Plan to pay for the moderate sedation time as billed. You say that it is felt this should be paid due to medical necessity. The Plan denied your request. The Plan says this code is not separately paid to the physician for services rendered in the facility setting.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting. We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the subsequent 15 minutes of moderation sedation services provided on December 3, 2020, billed with code 99153.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed tomography (CT) scan services.
You asked the Plan to pre-approve the PET/CT scan. You say that the enrollee needs a PET/CT brain scan for further evaluation, as it would be able to offer a more defined answer to the enrollee's symptoms and allow the best treatment options. The Plan denied your request. The Plan says the records do not show that he enrollee's cause of symptoms remains unclear.
The Plan follows Medicare rules. Medicare rules say that an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both AD and FTD. 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 PET/CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a more than 6-month history of cognitive impairment. However, she does not meet diagnostic criteria for both AD and FTD.
Rather, she is not specifically noted to meet diagnostic criteria for either condition at this time. The requested service cannot be said to be 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 PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) and computed tomography (CT) scan services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, and Pembrolizumab.
You asked the Plan to pre-approve Carboplatin, Paclitaxel, and Pembrolizumab. You say that this request is medically necessary. The Plan denied your request. The Plan says the request is not the standard of care.
The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel, and Pembrolizumab.