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

We decided that the Plan does not have to pay for physician's services provided on October 30, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
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 services 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 physician's services provided by on October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records, there is no evidence that the enrollee requires services that are not currently available. As acute care hospitals and an LTACH are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current hospital until such time no acute services are required. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says no x-ray reports of the knee that show osteoarthritis were provided.
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 injections. Our reviewer says that the requested injections are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient evidence that Supartz FX has clinically relevant benefit in patients with knee pain. Large, double-blinded trials have shown that intraarticular hyaluronic acid has a small, clinically irrelevant benefit over intraarticular placebo. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz injections for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Spine (72141, 72146).You asked the Plan to pre-approvethe MRI. You say that the MRI is medically necessary.The Plan denied your request. The Plan says rules for coverage 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 reviewer says that coverage criteria has not been met. Our physician reviewer found conservative measures and x-rays of spine have not been trialed and failed first. In this case there is no specific clinical rational for the requested MRI studies. There is no documentation of previous x-rays or any documented neurologic abnormalities on physical exam.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 not been met.Therefore, we decided that the Plan does not have to pre-approveMagnetic Resonance Imaging (MRI) of the Spine (72141, 72146).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 1, 2019. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.  
 
The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 pay for drug testing services provided to the enrollee on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the changing of the spinal cord stimulator (SCS) generator to a certain brand.
You asked the Plan to pre-approve the changing of the spinal cord stimulator (SCS) generator to a certain brand. You say that the requested changing of the SCS generator to a certain brand is medically necessary. The Plan denied your request. The Plan says the requested changing of the SCS generator to another brand 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 the changing of the spinal cord stimulator (SCS) generator to a certain brand. Our reviewer says that the requested changing of the SCS generator to a certain brand is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of Other chronic pain. Another spinal cord stimulator (SCS) was placed in June, 2019, with percutaneous leads for another spinal cord stimulator. The enrollee continues to report pain. A lumbar epidural steroid injection on 12/12/19 did not result in significant benefit. The proposed plan is to replace the recently placed generator SCS with a another brand, to see if this might better control her pain. While the enrollee in this case continues to have back pain following the placement of another SCS, the documentation does not support that the changing from another to a SCS is reasonably expected to impact the enrollee's pain.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the changing of the spinal cord stimulator (SCS) generator to another brand have not been met. Therefore, we decided that the Plan does not have to pre-approve the changing of the spinal cord stimulator (SCS) generator to a another brand.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe infectious agent detection (87507) provided on July 11, 2019 by an out of network (OON) provider.You asked the Plan to pay forinfectious agent detection. You say that this service was billed correctly.The Plan denied your request. The Plan says this service was not authorized.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 has network providers available who can provide 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 forthe infectious agent detection (87507) provided on July 11, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an anesthetic injection (64402). 
 
You asked the Plan to pay for the injection. You say that you would like reconsideration based on the record submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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. 
 
In this case, the CPT Code Manual definition of code 64402 is injection, anesthetic agent; facial nerve. 
 
We asked our coder 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 injection. Our reviewer says that CPT code 64402 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records submitted do not include documentation of an injection, anesthetic agent, facial nerve, therefore the service cannot be verified. We looked at this coder'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 pay for an anesthetic injection (64402).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on December 16, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that no prior authorization was 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 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 has network providers available who can provide 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 foran office visit provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to the enrollee on November 14, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 definitive drug testing rendered to the enrollee on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available for these services.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 has network providers available who can provide 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 an office visit provided on May 9, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for Emergency Room Services (0272, 82962, 99282) provided September 9, 2019.You asked the Plan to pay forthe Emergency Room Services. You say that the services were medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for payment for these services as the enrollee had invoked their hospice benefit.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forEmergency Room Services (0272, 82962, 99282) provided September 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe definitive drug testing rendered on September 30, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe definitive drug testing rendered on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty walker (E0149) and a seat attachment.You asked the Plan to pre-approvethe heavy duty walker with seat attachment. You say that the heavy duty walker is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that heavy duty walkers are only covered if an enrollee weighs more than 300 pounds. We looked at the file and Medicare rules. The medical records provided show your weight to be 272 pounds. This isless than the 300 pounds that is required in order for a heavy duty walker to meet coverage criteria. Based on this information, we decided that Medicare rules for coverage of the heavy duty walker with seat attachment have not been met.Therefore, we decided that the Plan does not have to pre-approvea heavy duty walker (E0149) and a seat attachment.Please note that the plan has indicated that they would consider covering the seat attachment if an appropriate walker that meets coverage rules is requested.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on September 30, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 drug testing rendered tothe enrollee on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a clindamycin phosphate injection (S0077) provided on August 27, 2019.You asked the Plan to pay for the clindamycin phosphate injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S0077 has a status code of I which 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.We find that CPT code S0077 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S0077 has a status indicator of I. This means that CPT code S0077 is notvalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the clindamycin phosphate injection have not been met. Therefore, we decided that the Plan does not have to pay for a clindamycin phosphate injection (S0077) provided on August 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay fora therapeutic procedure (97110) and manual therapy (97140) provided on August 22, 2019 through September 3, 2019.You asked the Plan to pay for the therapeutic procedure and manual therapy. You say that you would like reconsideration based on the recordssubmitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report serviceswith the appropriate CPT code.In this case, the CPT Code Manual definition of code 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.The CPT Code Manual definition of 97140 is manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes.We asked our coder 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 therapeutic procedure and manual therapy. Our reviewer says that CPT code 97110 does not meet criteria for billing or reimbursement consideration. The medical records provideddo not include documentation of the individual time spent for the services rendered, therefore, this service cannot be validated. Our reviewer found CPT code 97140 does not meet criteria for billing or reimbursement consideration.The medical records provided do not include documentation of the individual time spent for the services rendered, therefore, this service cannot be validated.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rulesfor coverage of the therapeutic procedure and manual therapy have not been met. Therefore, we decided that the Plan does not have to pay for a therapeutic procedure (97110) and manual therapy (97140) provided on August 22, 2019 through September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on July 16, 2019. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening 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 tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on July 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

e decided that the Plan does not have to pre-approve a Group 3 power wheelchair and accessories for the enrollee.You asked the Plan to pre-approvethese services. The Plan denied your request. The Plan says that the enrollee's mobility needs could be met with a lower level power wheelchair.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 a Group 3 power wheelchair is not medically reasonable and necessary for the enrollee in this case. The enrollee has long standing disability with multiple sclerosis and has 4/5 strength but is dependent for mobility and ADLs. The enrollee's mobility needs can easily be met with a lower level power chair. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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-approvea Group 3 power wheelchair and accessories for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 18, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 servicesat 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 physician's services provided on September 18, 2019.