Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient hospital care services.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested inpatient hospital admission is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital admission does not meet criteria.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.      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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the clinical value and effectiveness of irreversible electroporation ablation in the setting of locally advanced pancreatic adenocarcinoma have not been demonstrated in the peer-reviewed literature. The enrollee is not participating in a clinical trial for evidence development. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periapical x-ray (D0220), bitewing x-ray (D0270), limited oral evaluation (D0140), and extraction (D7140) provided from August 25, 2021, to September 1, 2021.  You asked the Plan to pay an additional amount for the dental services. You say that the dental office checked your insurance and advised you would be covered. You say that you were not advised that they were out of network. You also say that you would like more to be paid for these services. The Plan denied your request. The Plan says the claim was processed correctly. The Plan says limited oral evaluation is not listed as a covered service. The Plan also says out of network dentists may bill you for any amount greater than what the plan pays the provider.  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 and the periapical x-ray, bitewing x-ray, and extraction are listed as covered, there are out of network cost share amounts that apply. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Out of network dentists may also bill you for any amount greater than what the plan pays. Additionally, the limited oral evaluation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay an additional amount for the periapical x-ray (D0220), bitewing x-ray (D0270), limited oral evaluation (D0140), and extraction (D7140) provided from August 25, 2021, to September 1, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Eylea (J0178).  You asked the Plan to pre-approve Eylea. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products. The Plan also says that the enrollee has not tried any of the preferred agents.  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 Eylea. Our reviewer says that Eylea (J0178) meets the criteria for coverage. Our physician reviewer found the enrollee is noted to have diabetes, retinopathy and macular edema. The enrollee's visual acuity is noted as being 20/800 oculus dextrus (OD) and 20/60 oculus sinister (OS).  Our reviewer found that the enrollee has had three prior courses of Avastin therapy (2016, 2019, 2021), but is still noted to have edema. Our physician reviewer also found that both the Plan's visual acuity requirement (20/50 or worse) and step therapy requirement (Avastin, Mvasi or Zirabev) have been 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 Eylea have been met. Therefore, we decided that the Plan has to pre-approve Eylea (J0178).   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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on July 9, 2021.  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 codes S1015 and S8301 are not covered.  The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes. We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the supplies rendered on July 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the enteral formula (B4154) provided on June 7, 2021.  You asked the Plan to pay for the enteral formula. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a proof of delivery.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery. The documentation does not include a proof of delivery or itemized billing/shipping statement for the billed date of service.   The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the enteral formula (B4154) provided on June 7, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Euflexxa.  You asked the Plan to pre-approve Euflexxa. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 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 Euflexxa. Our reviewer says that the medication is not medically necessary. Our physician reviewer found based on the medical records provided there is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the moderate sedation services (G0500) provided on May 10, 2021.  You asked the Plan to pay for the moderate sedation services (G0500). You say that the patient reports are attached as the claim denied for lack of information. The Plan denied your request. The Plan says CPT code 92941 and 93454 were approved. The Plan also says the records do not support CPT code G0500 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 G0500 is moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate).  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 moderate sedation services (G0500). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the medical procedure documented does not support moderate sedation for a gastrointestinal endoscopic service, and therefore CPT code G0500 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 moderate sedation services (G0500) have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services (G0500) provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 16, 2021.  You asked the Plan to waive the copayment for arthrocentesis. You say that you disagree with the charges and feel that the services were billed incorrectly. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers.   The record shows that you received arthrocentesis at an outpatient hospital facility yon June 16, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment.   You have been asked to pay a $295 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 arthrocentesis provided on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular reeducation (97112), vasopneumatic device (97016), subcutaneous and intramuscular injection (96372), unclassified drug (J3490), thiamine injection (J3411), pyridoxine injection (J3415), and compounded drug, not otherwise classified (J7999) provided on September 1, 2021.  You asked the Plan to pay for the outpatient services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says these services are not Medicare covered benefits.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services by an NP or PA only when that NP/PA may perform physical therapy services under State law. The rules also say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  Upon review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular reeducation (97112), vasopneumatic device (97016), subcutaneous and intramuscular injection (96372), unclassified drug (J3490), thiamine injection (J3411), pyridoxine injection (J3415), and compounded drug, not otherwise classified (J7999) provided on September 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for infectious agent detection testing (87798) provided on March 29, 2021.  You asked the Plan to pay for infectious agent detection testing 87798. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 87798 has a procedure-to-procedure (PTP) edit of 1 with code 87801 so is not separately payable without an appropriate modifier.  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 87798 is a column II code to column I code 87801. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for infectious agent detection testing (87798) provided on March 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the arthrodesis (22551 and 22552) and insertion of interbody biomechanical device (22853) provided on April 19, 2021.  You asked the Plan to pay for the arthrodesis (22551 and 22552) and insertion of interbody biomechanical device (22853). You say that you have attached the operative note which supports the services rendered. You say that the claim should be reviewed and reconsidered for payment. The Plan denied your request. The Plan says the services 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.  In this case, the CPT Code Manual definition of code 22551 is arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2.  The CPT Code Manual definition of code 22552 is arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 22853 is insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure).  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 arthrodesis (22551 and 22552) and insertion of interbody biomechanical device (22853). Our reviewer says that the documentation was reviewed and does not meet the criteria for coverage. Our reviewer found that for CPT 22551, the operative report does not describe arthrodesis, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord. Since this procedure is not documented in the operative report it cannot be verified. CPT code 22552 is an add on code, and would not be covered, if the primary code is denied. The operative report also does not include documentation to support CPT 22853, and therefore 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 arthrodesis (22551 and 22552) and insertion of interbody biomechanical device (22853) have not been met. Therefore, we decided that the Plan does not have to pay for the arthrodesis (22551 and 22552) and insertion of interbody biomechanical device (22853) provided on April 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing rendered on May 4, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.      Therefore, we decided that the Plan does not have to pay for the drug testing rendered on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services related to end-stage renal disease (ESRD) provided from February 2, 2021, through February 26, 2021.  You asked the Plan to pay for the medical services. You say that you would like these services processed for payment. The Plan denied your request. The Plan says the claim has been billed with a missing or invalid modifier or ESRD services and a corrected claim is required.  The Plan must follow Medicare rules. Medicare rules say that modifiers are required with ESRD billing.   We looked at the file and Medicare rules. In this case, modifiers necessary to process this claim as required by Medicare rules are missing. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services related to end-stage renal disease (ESRD) provided from February 2, 2021, through February 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcatheter TTVI (CPT code 0646T) and inpatient admission.  You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of TTVI in the setting of severe tricuspid regurgitation with active carcinoid heart disease have not been demonstrated in the peer-reviewed literature. The Plan states the requested hospital stay is not covered because it is associated with a procedure that is not covered.  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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that the requested transcatheter tricuspid valve implantation is medically reasonable and necessary for the enrollee in this case. There are insufficient data to support that the requested procedure is an accepted standard of medical practice for the treatment of this enrollee's condition.  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 transcatheter TTVI (CPT code 0646T) and inpatient admission.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records show that the enrollee does not need daily therapy. The Plan states the services you require, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor. The Plan states you may discuss the best option with the enrollee's provider.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. This enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. This enrollee does not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.