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

We decided that the Plan does not have to pre-approve a cycling therapy system.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the effectiveness of this device in people with multiple sclerosis is limited.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the evidence for the effectiveness of the requested device in people with multiple sclerosis is limited. There is insufficient evidence in the literature that supports that the use of this device will be effective.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a cycling therapy system.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee has not failed a minimum 6-month intensive nonoperative treatment plan.
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 requested services are not considered medically reasonable and necessary in this case. There is not enough conservative measures for low back pain documented. The exact cause of the degenerative back pain remains unclear. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint arthrodesis for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Renflexis. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
i
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 a diagnosis of psoriatic 
arthritis. He has not tried and failed the Plan's required drugs, Remicade, Inflectra, Simponi Aria and/or Stelara. 
The records do not support that the required drugs would be contraindicated or less effective; therefore, 
Renflexis is 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Renflexis.mplement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel testing (code 81455) provided on February 16, 2021.
You asked the Plan to pay for genetic testing. You say that this testing was ordered by the enrollee's treating physician because the results were needed to help determine the course of treatment. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that testing code 81455 is unlikely to impact therapeutic decision-making and will be automatically denied as not medically necessary. We looked at the file and Medicare rules. 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 targeted genomic sequence analysis panel testing (code 81455) provided on February 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT Scan of the head and brain (70450) provided on March 23, 2021.

You asked the Plan to pay for the CT Scan of the head and brain. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says the appropriate National Correct Coding Initiative (NCCI) modifier has not been appended to CPT code 70450.

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 the CT Scan of the head and brain has a bundled relationship with code 70496 and cannot be paid as billed. Though NCCI edits allow for a modifier, no modifier has been appended to this CPT code to identify this service as distinct. 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 CT Scan of the head and brain (70450) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fitting for foot orthotics. 
 
You asked the Plan to pre-approve a fitting for foot orthotics. You say that you have been using orthotics for 
over 20 years and need new ones to replace your old ones. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve a fitting for foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87641) provided on April 15, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a column two
code and is not payable.

The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair,
the column two code is denied, and the column one code is eligible for payment. Procedure code 87641 is part
of an edit pair with procedure code 87150. Procedure code 87150 is a column one code, and procedure code
87641 is a column two code. Procedure code 87150 has been billed for this date of service, which means that
procedure code 87641 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for
the services (87641) provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of anterior segment aqueous drainage device (0376T) provided on January 25, 2021.

You asked the Plan to pay for Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in
addition to code for primary procedure). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the billing of code 0376T in addition to 0191T is inappropriate.

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 the claim cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the trabecular meshwork; each additional device insertion (List separately in addition to code for primary procedure) have not been met. Therefore, we decided that the Plan does not have to pay for insertion of anterior segment aqueous drainage device (0376T) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a surgeon on March 17, 2021.
You asked the Plan to waive the copayment for the visit with a surgeon. You say that you typically see a different doctor. You say that the doctor you saw on this date only spent fifteen minutes with you. The Plan denied your request. The Plan says you were charged this copayment correctly.
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 $35 copayment for visits with a specialist. You have been asked to pay a $35 copayment for the visit with a surgeon. This copayment applies regardless of how long the doctor spends with you. 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 copayment for the visit you had with a surgeon on March 17, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fecal transplant (44705).
You asked the Plan to pre-approve the transplant. You say that the best option is the fecal transplant. The Plan denied your request. The Plan says this is not valid for Medicare purposes.
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 44705 is "preparation of fecal microbiota for instillation, including assessment of donor specimen." We find that CPT code 44705 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the transplant have not been met. Therefore, we decided that the Plan does not have to pre-approve a fecal transplant (44705).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telemedicine visit you had with your 
primary care provider on March 31, 2021. 
 
You asked the Plan to waive the copayment for the telemedicine visit. You say that you were not aware that 
there would be a copayment for this eervice. The Plan denied your request. The Plan says you were charged 
this copayment correctly. 
 
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 $10 
copayment for visits or consultations with your primary care provider, including telehealth services. You have been asked to pay a $10 copayment for the telemedicine visit. 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 copayment for the telemedicine visit you had with your primary care provider on March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable


We decided that the Plan does not have to pre-approve continued inpatient hospital care for detox from August 
15, 2021 and forward. 
 
You asked the Plan to pre-approve continued inpatient hospital care for detox from August 15, 2021 and 
forward. You say that the continued inpatient hospital care for detox from August 15, 2021 and forward is 
medically necessary. The Plan denied your request. The Plan says the continued inpatient hospital care for 
detox from August 15, 2021 and forward is 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 continued inpatient hospital care for 
detox from August 15, 2021 and forward. Our reviewer says that the continued inpatient hospital care for detox 
from August 15, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did 
not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to 
herself or others, no auditory hallucinations or visual hallucinations while being cooperative with treatment. It 
did not appear that active treatment was taking place beyond the date in question. It did not appear that the 
services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond 
the date in question. I am unable to find an individualized treatment plan however it is alluded to in the record. 
It did appear that the records were supervised and evaluated by a physician. Based upon review of the records 
provided, this enrollee does not meet the criteria for continued acute inpatient mental health treatment for the 
dates in question of August 15, 2021 and forward as this enrollee was not shown to be a danger to herself or 
others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with 
treatment. This enrollee was not showing any aggressive behaviors, or any treatment required for acute threats 
of safety. She was not experiencing severe withdrawal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued inpatient hospital care for detox from August 15, 2021 and forward 
have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient 
hospital care for detox from August 15, 2021 and forward.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for circulating tumor cell (CTC) assay testing provided on January 8, 2021.
You asked the Plan to pay for CTC assay testing. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this
testing is considered experimental/investigational.
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 pay for CTC assay testing. Our reviewer says that
the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found CTCs can be detected in the systemic circulation of men with prostate cancer, and the presence
of an increasing number of CTCs at baseline has been associated with shorter OS in several trials. Tumors from
a majority of patients with metastatic castrate resistant prostate cancer harbor mutations in genes involved in
the androgen receptor signaling pathway. AR-V7 testing in circulating tumor cells (CTCs) can be considered to
help guide selection of therapy in the post-abiraterone/enzalutamide metastatic CRPC setting. Use is supported
by the NCCN Guidelines and the medical literature. Changes in the number of CTCs may be an indicator of
response to treatment and subsequent improved survival. In this patient considering chemotherapy baseline
CTCs can help guide response to treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CTC assay testing have been met. Therefore, we decided that the Plan has to
pay for circulating tumor cell (CTC) assay testing provided on January 8, 2021.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for COVID-19 pneumonia and bacteremia. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the dental services provided December 14, 2020.

You asked the Plan to pay for the dental services provided December 14, 2020. You say that you would like the
services covered. The Plan denied your request. The Plan says that the services were provided out-of-network
and therefore are not covered.

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 dental
services when the are received from a participating provider.

We looked at the file and Medicare rules. In this case the Plan indicated the claims were denied due to the
provider being out-of-network. The provider's name appears to be misspelled throughout the case file and upon
reviewing the Plan's website, it appears that this provider is a participating provider. We requested additional
information from the Plan about the claims at issue and the denial rationale. The Plan failed to provide the
requested information prior to the due date. Based on the information available for review, we decided that the
Plan's rules for coverage of the dental services have been met. Therefore, we decided that the Plan has to pay
for the dental services provided December 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (85060) provided January 6, 2021.
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 claim cannot be paid 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 code 85060 is not supported in the medical record. Specifically, the CPT code billed has a
PC/TC indicator of 8. Place of Service 22 is not a valid place of service for the code billed. 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 (85060) provided January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) of the head (70450) provided March 25, 2021.
You asked the Plan to pay for the CT scan. You say that the service was medically necessary. The Plan denied your request. The Plan says the CPT code billed has a bundled relationship with another code billed and is not separately payable.
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 70450 has a bundled relationship with code 70496 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 computed tomography (CT) of the head (70450) provided March 25, 2021.