Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277) and gel-like pressure pad for mattress (E0185).
You asked the Plan to pre-approve the mattress and pressure pad. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the records did not support the medical necessity for this service.
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 mattress and pressure pad. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee in this case is status post rotator cuff surgery to both shoulders and status post stent in bilateral legs, with a history of coronary bypass surgery, sciatica, hypertension, hyperlipidemia, and morbid obesity. The notes provided did not show evidence via problem list or physical findings of ongoing skin breakdown or frank wounds or a condition that would limit the ability for her to change positions in bed. A request was made for a powered pressure-reducing air mattress (E0277) and gel-like pressure pad for mattress (E0185), however, there was insufficient support made for this request to meet the criteria. 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 mattress and pressure pad have not been met. Therefore, we decided that the Plan does not have to pre-approve the powered pressure-reducing air mattress (E0277) and gel-like pressure pad for mattress (E0185).
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 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. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 24, 2020 with progressive weakness. The physical therapy note on August 18, 2020 states that he needs maximal assist to sit up and to place on slide board. He needs modified to maximal assist with sitting and bed transfers. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The IRF services are not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J9155).
You asked the Plan to pre-approve Prolia. You say that without Prolia the enrollee is at high risk for fracture. You also say that the enrollee has received one injection and tolerated it well. The Plan denied your request. The Plan says the Plan's criteria for coverage of Prolia has not been met.
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 Prolia. Our reviewer says that step therapy criteria have not been met. Our physician reviewer found there is no evidence that the enrollee is allergic to, intolerant of or non-responsive to other osteoporosis medications. The enrollee has received at least one dose of androgen deprivation therapy (ADT), and there is no documentation as to whether the enrollee is continuing to receive ADT. Our reviewer found that the documentation is unclear as to whether or not the enrollee has metastatic or non-metastatic prostate cancer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J9155).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve commode chair, extra wide and/or heavy duty,
stationary or mobile, with or without arms, any type, each (E0168).
You asked the Plan to pre-approve the commode chair. You say that you have gained some weight and cannot
fit into the regular size commode. The Plan denied your request. The Plan says the Medicare rules have not
been met.
The Plan must follow Medicare rules. The rules say that heavy duty commodes may be covered for members
who weigh 300 pounds or more.
Based on the information we received, you weigh 280 pounds. Additionally, there is no evidence that you are
physically incapable of utilizing regular toilet facilities. Therefore, we decided that the Plan does not have to
pre-approve commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any
type, each (E0168).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve myocardial perfusion imaging, tomographic (SPECT) (CPT Code
78452), for the enrollee.
You asked the Plan to pre-approve the imaging. You say that you believe the testing is necessary. The Plan
denied your request. The Plan says that the Medicare rules have not been met.
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 imaging. Our physician reviewer
found progressive or new shortness of breath with no pother cause is suspicious for ischemic heart disease and
stress testing is indicated and would be considered standard of care. Stress imaging is both reasonable and
appropriate.
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 imaging have been met. Therefore, we decided that the Plan has to preapprove
myocardial perfusion imaging, tomographic (SPECT) (CPT Code 78452), 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says no documentation was received supporting the medical necessity for a step therapy exception.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found 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. Therefore, we decided that the Plan does not have to pre-approve a Synvisc injection for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Krystexxa.
You asked the Plan to pre-approve Krystexxa. The Plan denied your request. The Plan says this is not medically necessary.
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 Krystexxa. Our reviewer says that Krystexxa is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the enrollee is noted to have tophaceous gout. He was previously on allopurinol, but the documentation does not note how long the he took the allopurinol or whether he was compliant with taking the medication. The documentation seems to indicate that the enrollee stopped taking the medication on his own accord because he didn't think it was working. Subsequently, the enrollee was noted to have a normal serum uric acid level while not on any gout medication. As such, the documentation does not demonstrate that the enrollee has gout that was/is refractory to conventional therapy. Therefore, the requested medication is not shown to be currently 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 Krystexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Krystexxa.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the MRI, any joint of lower extremity; without contrast material (CPT Code 73721).
You asked the Plan to pre-approve the MRI. You say that the MRI is necessary. The Plan denied your request. The Plan says that the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our physician reviewer found the provider has evaluated knee on multiple occasions and ordered imaging of the knee. The pain is persistent. Pain is also going to be aggravated on a daily basis based on occupation. It is unlikely that a six-week trial will be of any benefit than delaying diagnosis. The MRI is indicated and appears necessary for proper diagnosis and treatment plan. 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 MRI have been met. Therefore, we decided that the Plan has to pre-approve the MRI, any joint of lower extremity; without contrast material (CPT Code 73721).
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 genetic testing provided to the enrollee on February 14,
2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on February 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic chiropractic services provided from February 18, 2020 to March 11, 2020.
You asked the Plan to pay for services not related to manual manipulation of the spine. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says only those services related to manual manipulation of the spine can be reimbursed.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for therapeutic chiropractic services provided from February 18, 2020 to March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 11, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says The Plan says this is an administrative determination for coding and is not based on clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. 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 claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 4, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on March 28, 2020.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says The Plan says this is an administrative determination for coding and is not based on
clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use
of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field.
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing
provided to the enrollee on March 28, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT, head or brain; without contrast material (70450)
provided to the enrollee on February 27, 2020.
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. The
CMS Correct Coding Initiative (CCI) has identified column I procedure codes and their associated column II
procedure codes based on the principles of correct coding. Services that are considered column II procedures to
another service are not eligible for reimbursement when billed with the column I procedure code. Procedure
code 70450 was denied as the column II code to the column I code 70496 but a modifier is allowed in order to
differentiate between the services provided. Review of the medical records support 70450 as rendered, but it
does not support this service as being performed separately and distinct from CPT code 70496. Therefore, we
decided that the Plan does not have to pay for the CT, head or brain; without contrast material (70450)
provided to the enrollee on February 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 & 9 and prefabricated posts and cores in addition to crowns (D2954) for tooth #'s 8 & 9.
You asked the Plan to pre-approve the crowns and posts and cores. The Plan denied your request. The Plan says placing a post and core and crowns on teeth #8 and #9 in their current state is not recommended, not medically necessary, and does not meet the coverage criteria.
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 covers the crowns and posts and cores when the services are medically necessary and reasonable. 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 crowns and posts and cores. Our reviewer says that the services are not medically necessary at this time. Our physician reviewer found the apparent insufficient root canal treatment should be addressed prior to the proposed treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crowns and posts and cores have not been met. Therefore, we decided that the Plan does not have to pre-approve crowns (D2750) for tooth #'s 8 & 9 and prefabricated posts and cores in addition to crowns (D2954) for tooth #'s 8 & 9.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on March 16, 2020 and
billed under codes 81120, 81121, 81173, 81201, 81210, 81235, 81272, 81293, 81310, 81311, 81314, and
81321.
You asked the Plan to pay this claim. You say that this testing should be covered by the Plan. The Plan denied
your request. The Plan says this claim cannot be paid as billed per the Medicare LCA. The claim should be
billed with code 81479 and the DEX Z identifier (ID).
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 claim is missing the main code
and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of
this claim have not been met.
Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on March 16,
2020 and billed under codes 81120, 81121, 81173, 81201, 81210, 81235, 81272, 81293, 81310, 81311, 81314,
and 81321.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 24, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says The Plan says this is an administrative determination for coding and is not based on clinical criteria. The Plan says that Comprehensive Genomic Profile (CGP) testing Guardant-360 requires use of CPT 81479, and the appropriate DEX Z identifier entered adjacent in the comment narrative field. Medicare billing criteria are not met.
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 claim is missing the main code and identifier required by Medicare. Based on this information, we decided that Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing provided to the enrollee on February 24, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an opt out provider received on January 29, 2020.
You asked the Plan to pay for these services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not payable.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the services provided by an opt out provider received on January 29, 2020.