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

We decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies (95909), and an electroencephalogram (95955) provided on March 11, 2020.
You asked the Plan to pay for needle electromyography, nerve conduction studies, and an electroencephalogram. You say that these procedures are documented. The Plan denied your request. The Plan says these codes are 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. 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 needle electromyography, nerve conduction studies, and an electroencephalogram. Our reviewer says that these codes are not supported. Our physician reviewer found the technical report does not include enough documentation to confirm needle electromyography was performed. Nerve conduction studies are also not documented as performed. An electroencephalogram is included in intraoperative neuromonitoring procedure code when performed and is not separately payable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography, nerve conduction studies, and an electroencephalogram have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies (95909), and an electroencephalogram (95955) provided on March 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223) and the therapeutic drug injection (D9612).
You asked the Plan to pre-approve the deep sedation and injection services. You say that you would like reconsideration because you have a condition where your extremities jump while receiving dental work. The Plan denied your request. The Plan says CPT code D9612 is not a covered benefit and sedation is only covered when the member needs a lot of dental work done on the same day, four of more teeth pulled or the patient is nervous and other drugs have been tried and failed.
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 deep sedation and injection services 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 deep sedation and injection services. Our reviewer says that there is no narrative from the provider regarding the need for sedation. Our physician reviewer found there is no documentation as to attempted and failed sedation with oral medication. Given the Plan provisions there would not be necessity for the procedures D9222 and D9223 given the documentation provided. Additionally, there does not appear to be an allowance for CPT code D9612.
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 deep sedation and injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223) and the therapeutic drug injection (D9612).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
You asked the Plan to preapprove the CGM. You say that the enrollee requires the CGM. The Plan denied your request. The Plan says the enrollee is not using insulin three or more times per day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration because the compression stockings help keep the swelling in your legs down. The Plan denied your request. The Plan says the requested items do not meet the statutory definition of a dressing and are therefore non-covered under the surgical dressing benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140), and the periapical x-ray (D0220) provided on July 1, 2020.
You asked the Plan to pay for the dental services. You say that D0140 should have been sent as D0150. You also say that this service should have been paid. The Plan denied your request. The Plan says limited oral evaluation is not listed as a covered service. The Plan says that periapical x-ray is not listed as a covered service either. The Plan also says that the Plan must process claims with the information submitted on the claim form and apply benefits based upon the terms and provisions of the plan.
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. The record shows that the Plan made multiple requests for records to ensure the claim was coded correctly, however no records were received. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140), and the periapical x-ray (D0220) provided on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on
November 24, 2020.
You asked the Plan to pay for the molecular pathology services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the molecular pathology services. 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 molecular pathology services provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair.
You asked the Plan to pre-approve the Group 3 Power Wheelchair. You say that you would like reconsideration because the requested power wheelchair is what is needed to help the member be functional in her home. The Plan denied your request. The Plan says the member does not have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3 Power Wheelchair.
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 would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for surgical treatment of a hip fracture after a fall. The enrollee's medical problems are stable. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services rendered on September 1, 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 15275 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 15275 is application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. We find that CPT code 15275 is not supported in the medical record. Specifically, there is no documentation that the code was billed with a low-cost skin substitute. 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 wound care services rendered on September 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy (PBT) and Image Guided Radiation Therapy (IGRT).
You asked the Plan to pre-approve PBT and IGRT. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 PBT and IGRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in other words, the need for proton therapy is usually established with quantitative dosimetric information that shows a clinically meaningful reduction in radiation dose exposure of normal tissues. The coverage criteria were not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBT and IGRT have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam therapy (PBT) and Image Guided Radiation Therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for support strap (A4467 and 99072) provided to you on October 8, 2020.
You asked the Plan to pay for the support garments. You say that you did not know that you would be charged separately for the items. The Plan denied your request. The Plan says the fabric support garments are noncovered.
The Plan must follow Medicare rules. Medicare rules say that elastic or other fabric support garments with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Code A4467 and 99072 are denied as noncovered (no Medicare benefit). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the support garments have not been met. Therefore, we decided that the Plan does not have to pay for support strap (A4467 and 99072) provided to you on October 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.
You asked the Plan to pre-approve Retacrit. You say that you would like reconsideration because the use of this drug is urgent and medically necessary. The Plan denied your request. The Plan says Retacrit is not indicated for chemotherapy induced anemia when the cancer is being treated with a curative intent.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Retacrit. Our reviewer says that Retacrit is not FDA approved for the member's diagnosis. Retacrit is also not supported by any of the major drug compendia or clinical research. Our physician reviewer found Retacrit is specifically not indicated in cancer patients receiving myelosuppressive chemotherapy when the expected outcome is curative. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on October 28, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 physician services provided on October 28, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from May 16, 2019 to May 20, 2019.
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 DRG is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis code J96.01. 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 these services. Our reviewer says that the DRG is not supported by the submitted medical records. Our physician reviewer found the enrollee presented to the emergency department (ED) with shortness of breath and facial and neck swelling after ingesting shellfish the day prior. On presentation, enrollee's symptoms were associated with an angioedema and an allergic reaction.
In the ED, the enrollee's vital signs were stable with no respiratory distress, respiratory rate of 16 and oxygen saturation of 96 percent on room air. The records do not support the billing of diagnosis code J96.01 (acute respiratory failure with hypoxia) and DRG 208 RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPOR<=96 HOURS. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from May 16, 2019 to May 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed (E0250) provided on November 16, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the hospital bed. You say that you would like to be reimbursed for the durable medical equipment you received from an OON provider. The Plan denied your request. The Plan says prior authorization was not obtained for this non-emergent service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the hospital bed (E0250) provided on November 16, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/mL (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of Oral Bisphosphonates and Zoledronic Acid is required before alternatives like Prolia can be considered.
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 Prolia is not medically necessary. Our physician reviewer found the records provided show no trial of the plan preferred drugs, or any reason why the plan preferred drugs would be unsafe or ineffective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/mL (J0897).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0676).
You asked the Plan to pay for a pneumatic compression device. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is not a covered service.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. 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, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0676).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Home Health Aide (HHA)services.
You asked the Plan to pre-approve HHA services. You say that the enrollee needs medication application. The Plan denied your request. The Plan says the notes do not show the enrollee continues to have a medical problem that needs special care that only a nurse can do.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 HHA services. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested services meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2. Based on the medical records provided there is no documentation that the home health aide services are reasonable and necessary to the treatment of the patient's illness or injury by skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve Home Health Aide (HHA)services.