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

We decided that the Plan does not have to pre-approve pain management services received on December 29, 2020.
You asked the Plan to pre-approve the services. You say that you were in pain and could not travel back home. The Plan denied your request. The Plan says prior authorization must be obtained.
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 pain management services received on December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479, 82397) provided September 25, 2020.

You asked the Plan to pay for genetic testing. You say that the test was medically necessary. The Plan denied your request. The Plan says this procedure is not covered under Medicare.

The Plan must follow Medicare rules. Medicare rules say that Prometheus IBD sgi Diagnostic tests are not covered. 

We looked at the file and Medicare rules. The procedure at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479, 82397) provided September 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on October 20, 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 procedure code 92136 is not supported.
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 CPT Code Manual definition of code 92136 is ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation.
We find that CPT code 92136 is not supported in the medical record. Specifically, there is no documentation of ophthalmic biometry by partial coherence interferometry with intraocular lens power calculation was performed. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on October 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary for your condition. The Plan denied your request. The Plan says this service is considered experimental and 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 the Vertiflex procedure. 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 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 the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spinal fusion surgery.
You asked the Plan to pre-approve spinal fusion surgery. You say that you are unable to manage your pain. The Plan denied your request. The Plan says you have had two previous spinal fusion procedures and another is unlikely to be effective.
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 spinal fusion surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the submitted medical records do not document spinal instability or fracture. A third spinal fusion surgery is not likely to help with chronic back 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 spinal fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spinal fusion surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Intracept procedure is not medically reasonable and necessary.
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 Intracept 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 Intracept procedure remains experimental for the treatment of low back pain. More research is needed to show safety and efficacy of the procedure. 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography, each extremity, complex study (95886) nerve conduction studies for 1-2 studies (95907) provided March 9, 2020.
You asked the Plan to pay for the neuromonitoring services. You say that the neuromonitoring was performed because the surgeon felt it was medically necessary and in the best interest of the enrollee. The Plan denied your request. The Plan says the procedure codes are not supported by the medical records submitted.
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 CPT Code Manual definition of CPT code 95886 is complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study, for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure) and CPT code 95907 is described as nerve conduction studies; for 1-2 studies. 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 neuromonitoring services. Our reviewer says that the medical records provided will show proof of medical necessity. Our physician reviewer found in this case the enrollee underwent a surgical procedure with monitoring. The procedure note provided does not completely describe the elements of CPT code 95886-26 X2. Therefore, this code is not reimbursable under Medicare rules. Because CPT 95886 is not covered, CPT code 95907 is not payable. The requested coverage cannot be recommended. 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 neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography, each extremity, complex study (95886) nerve conduction studies for 1-2 studies (95907) provided March 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided to the enrollee on March 17, 2021 and billed under code 23430.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request.

The Plan says NCCI edits show that CPT code 23430 is a component of CPT code 23472. The exception listed in the NCCI Policy Manual, Chapter IV, Section E, Subsection #7, applies only to arthroscopic procedures, not open procedures. The documentation shows both procedures were performed on the same shoulder (i.e. ipsilateral shoulder). Therefore, only CPT code 23472 may be reported.

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, code 23430 has a bundled relationship with code 23472 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 to pay for services provided to the enrollee on March 17, 2021 and billed under code 23430.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 11, 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 services are 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, a cardiovascular risk assessment panel, 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 the laboratory services rendered on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for acupuncture services received on January 20, 2021.
You asked the Plan to pay for the services. You say that you were told that these services would be covered. The Plan denied your request. The Plan says these services are not covered by Medicare.
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 chronic low back pain meeting certain requirements. 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, these services are only covered specifically for low back pain. The enrollee's diagnosis is left shoulder pain. Therefore, we decided that the Plan does not have to pay for acupuncture services received on January 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Rituximab biosimilar (Truxima) injection for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary to treat bullous
pemphigoid. The Plan denied your request. The Plan says that medical policy does not support retreatment with
rituximab.
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 is medically reasonable and necessary. Our physician reviewer found the diagnosis of bullous
pemphigoid has been established based on biopsy and serology. Rituxan is the standard of care of bullous
pemphigoid.
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 been met. Therefore, we decided that the Plan has to pre-approve
Rituximab biosimilar (Truxima) injection for the enrollee.
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 hospital discharge day management services coded 99239 provided on December 11, 2020.

You asked the Plan to pay for the hospital discharge day management services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. 

We find that CPT code 99239 is not supported in the medical record. Specifically, the documentation submitted does not support that more than 30 minutes was spent on hospital discharge services for this date of service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met. Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99239 provided on December 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on November 12, 2020.

You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that documentation indicates services are not necessary for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.

A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthoses and sleeves provided to the enrollee on November 12, 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 you are not able to return to independent living with
your current medical situation. The Plan denied your request. The Plan says you do not need an intensive team
for care.

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 acute renal failure with hydronephrosis and a pelvic mass.
Your medical conditions are stable. There are no complex nursing needs. The complexity of your nursing,
medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary
approach to rehabilitation 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network services provided to the enrollee on February 11, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 service 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 out of network services provided to the enrollee on February 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88141, 87624, 88142) provided on January 12, 2021 by an out of network (OON) provider.

You asked the Plan to pay for laboratory services. You say that you believed the services were referred by an authorized provider. The Plan denied your request. The Plan says the referral for these services was not made by an in-network 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 laboratory services (88141, 87624, 88142) provided on January 12, 2021 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 80299, 82542, and 80307 provided on December 16, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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. 

We find that CPT codes 80299, 82542, and 80307 are not supported in the medical record. Specifically, code 80299 is considered unbundled. This code is included in the primary procedure. Codes 82542 and 83789 are disallowed as testing for substances using column chromatography and/or mass spectrometry (including stereoisomers) are to have been counted in the number of drug classifications studied to determine the appropriate confirmatory drug testing code.

These are also inclusive to G0482. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 80299, 82542, and 80307 provided on December 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has spinal stenosis at three levels. The Superion spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The services are therefore not reasonable or medically necessary for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gradient compression stockings.
You asked the Plan to pre-approve the gradient compression stockings. You say that these items are medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that gradient compression stockings are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve the gradient compression stockings.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the finger splint rendered on December 18, 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 procedure code Q4049 is not covered.
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid
for Medicare purposes.
We looked at the file and Medicare rules. Billed procedure code Q4049 (static finger splint) has a status
indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay
for the finger splint rendered on December 18, 2020.