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

We decided that the Plan has to pay for the hydration therapy rendered on May 14, 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 that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services were rendered in the state of New Jersey and that Local Coverage Determination (LCD) L34960 is binding; however, there is no documentation in the file to support that the services were rendered in New Jersey. The claim dispute form lists a National Provider Identifier (NPI) number that is listed as located in New York. The Plan has not provided any further documentation or rules to support that the services are not payable. Therefore, we decided that the Plan has to pay for the hydration therapy rendered on May 14, 2020.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869).
You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested service is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure 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 procedure at issue is still considered experimental/investigational. 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 pre-approve a Vertiflex procedure (22869).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99284) provided on February 1, 2021.
You asked the Plan to pay for an emergency room visit. You say that the enrollee had two visits on this date. The Plan denied your request. The Plan says this is not separately payable without a modifier.
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, we have confirmed that code 99284 has a bundled relationship with code 99285 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99284) provided on February 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injections (J9271) provided from July 1, 2020, through July 22, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.
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 20% coinsurance for Medicare-covered Part B drugs. You have been asked to pay $2,978.72 ($14,893.60 x 20%) for the Medicare Part B drugs provided. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the pembrolizumab injections (J9271) provided from July 1, 2020, through July 22, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a repeat lumbar sacral facet joint radiofrequency neurolysis.
You asked the Plan to pre-approve repeat destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or computed tomography); lumbar or sacral, single facet joint (64635). You say that the enrollee needs the radiofrequency neurolysis for lower back pain and numbness relief. The Plan denied your request. The Plan says that the enrollee does not meet LCD criteria.
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 repeat destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635). Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had right L4-L5 and L5-S1 radiofrequency ablation (RFA) and achieved 50-75% pain relief for 6 months. The patient had a successful RFA result which lasted more than 6 months. The request is 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 repeat destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint (64635) have been met. Therefore, we decided that the Plan has to pre-approve a repeat lumbar sacral facet joint radiofrequency neurolysis.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on November 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services. You say that you should not have to pay for this because customer service gave you this provider's name and phone number. The Plan denied your request. The Plan says the provider is out-of-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. The record shows the phone call to customer service was placed on December 3, 2020. Therefore, we decided that the Plan does not have to pay for the podiatry services provided on November 27, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve trigger point injections.
You asked the Plan to pre-approve trigger point injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that trigger point injections are only covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve trigger point injections. Our reviewer says that the documentation supports that the requested trigger point injections are medically reasonable and necessary. Our physician reviewer found the enrollee as chronic neck pain and headaches. The enrollee is taking Hydrocodone, Effexor, Ibuprofen, Gabapentin and Fiorinal. The enrollee has had prior Trigger Point Injections which with other therapies provided 90% pain relief and improved function. The prior injections were done utilizing ultrasound guidance. The proposed treatment will also be ultrasound guided. The enrollee meets LCD criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of trigger point injections have been met. Therefore, we decided that the Plan has to pre-approve trigger point injections.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the office visits. You say that you want a doctor who specializes in mesh-less hernia surgery. The Plan denied your request. The Plan says the provider is out-of-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 provider at issue in this case is not a network provider with the Plan. 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 office visits. Our reviewer says that the office visits are not medically necessary. Our physician reviewer found the record did not include a surgical assessment.
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 office visits have not been met. 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 the office visits. Therefore, we decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultralight manual wheelchair.
You asked the Plan to pre-approve an ultralight manual wheelchair. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.
The Plan must follow Medicare rules. Medicare rules say that ultralight manual wheelchairs are only covered for certain indications.
We looked at the file and Medicare rules. Review of the file shows that your medical needs can adequately be
met with a lightweight manual wheelchair. You can independently propel your manual wheelchair in your
home. The documentation does not support that you need the special features of the ultralight wheelchair.
Based on this information, we decided that Medicare rules for coverage of an ultralight manual wheelchair
have not been met. Therefore, we decided that the Plan does not have to pre-approve an ultralight manual
wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the requested Keytruda is medically necessary. The Plan denied your request. The Plan says the requested Keytruda is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 requested Keytruda is not medically necessary. Our physician reviewer found the enrollee is diagnosed with recurrent squamous non-small cell lung cancer (NSCLC). The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. PD-L1 is 0 and no ALK or EGFR is provided. The requested use of Keytruda is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care visits.
You asked the Plan to pre-approve home health. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for home health care is correct.
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. Our reviewer says that you do not meet the Medicare criteria for the requested home health visits. Our physician reviewer found based on the medical records provided your vital signs were reported as normal, breathing normal, and no report of pain. There is no documentation that you remain homebound. The records do not show that skilled nursing and/or therapy services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish or perform a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health have not been met. Therefore, we decided that the Plan does not have to pre-approve home health care visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis or in an inpatient 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 SNF admission have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means that admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the injection procedure for sacroiliac joint (27096).
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of an SI joint injection in the absence of a physical examination documenting positive provocation testing have not been demonstrated in the peer-reviewed literature.
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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no documentation of the physician's physical examination findings, and in particular any supportive provocative testing to diagnose SI joint pain.
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 injection have not been met. Specifically, without a physical examination documenting positive provocation testing, the service is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the injection procedure for sacroiliac joint (27096).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Life Alert Alarm device.
You asked the Plan to pre-approve Life Alert Alarm device. You say that the item is medically necessary. The Plan denied your request. The Plan says this item is not medical in nature.
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 Life Alert Alarm device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia supplies (S1015, S8301) provided December 2,
2020.
You asked the Plan to pay for the anesthesia supplies. You say that the items were medically not necessary.
The Plan denied your request. The Plan says the CPT codes billed are not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, per the
National Physician Fee Schedule, the CPT codes billed have a status of "I" and are invalid for Medicare
purposes. Based on this information, we decided that Medicare rules for coverage of the anesthesia supplies
have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia supplies (S1015,
S8301) provided December 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is a high-risk cardiovascular patient. The Plan denied your request. The Plan says the enrollee's therapy and nursing needs can be provided on an intermittent basis.
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 physician reviewer found that you were admitted to the acute care hospital for non-operative management of radial fracture and pelvic fractures after a fall. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies in an intensive rehab therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehab program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0031U, 0032U, 81225, 81226, 81240, 81241,
81291, 81355) provided June 26, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were not correctly billed.
The Plan must follow Medicare rules. Medicare rules say that if a laboratory assays two or more genes in a
patient in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes
a single procedural service, so one HCPCS code must be submitted for the panel.
We looked at the file and Medicare rules. The testing formed was for multiple genes in parallel. This service
must be billed using a single code. The service in this case was billed using unbundled codes. Based on this
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we
decided that the Plan does not have to pay for lab services (0031U, 0032U, 81225, 81226, 81240, 81241,
81291, 81355) provided June 26, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a crown (D2740), and a corebuildup (D2950) provided on February 11, 2021.
You asked the Plan to pay for a crown, and a corebuildup. You say that you were not aware that your Plan benefits had changed. The Plan denied your request. The Plan says the services at issue are not covered 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 pay for a crown (D2740), and a corebuildup (D2950) provided on February 11, 2021.