Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Celecoxib.
You asked the Plan to pre-approve Celecoxib. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Celecoxib.
Benefits for Celecoxib may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator, single delivery port (E1390) provided on January 25, 2021.

You asked the Plan to pay for the durable medical equipment (DME). You say that the provider in this case is and in network DME provider with the enrollee's plan. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits
starting on the date of election until the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.

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 for the oxygen concentrator, single delivery port (E1390) provided on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient admission and services
provided from March 23, 2021, to March 28, 2021.
You asked the Plan to waive the copayment for the inpatient care. You say that these services were medically
necessary, and you are on a fixed income and cannot afford this bill. The Plan denied your request. The Plan
says the inpatient care is covered, but you are responsible for your share of the cost as indicated in your
contract.
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 $325
copayment for each of the first five days of a Medicare-covered inpatient hospital stay. There is a $0
copayment for additional days.
You have been asked to pay a $1,625 copayment for a six-day inpatient hospital stay ($325 x 5 = $1,625). 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 inpatient admission and services provided from March
23, 2021, to March 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a CardioPro genetic panel (81201, 81317, 81407, 81408) provided on August 5, 2020.
You asked the Plan to pay for a CardioPro genetic panel. You say that this was billed correctly. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a CardioPro genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a CardioPro genetic panel (81201, 81317, 81407, 81408) provided on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve Intracept. You say that significant clinical and diagnostic data supports the
necessity of this procedure. The Plan denied your request. The Plan says the denial of authorization for this
service is correct, because this procedure is experimental/investigational.
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 Intracept. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Intracept procedure remains experimental, more research is needed to show its safety and
efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the out-of-network (OON) provider on May 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the out-of-network (OON) provider on May 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit for hemo-dialysis (99512) and darbepoetin
alfa injection (J0882) provided from May 3, 2021, to May 14, 2021.

You asked the Plan to pay for the home health services. You say that the services in this case should be
covered. The Plan denied your request. The Plan says the provider in this case does not participate with
Medicare. The Plan also says that a provider must be participating with Medicare to receive payment except for
emergency services.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the home visit for hemo-dialysis (99512)
and darbepoetin alfa injection (J0882) provided from May 3, 2021, to May 14, 2021.
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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met at a lower level of care.
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's current medical stability and lack of medical complexity do not require a rehabilitation physician a minimum of 3times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no documented skilled nursing needs. The enrollee is functionally doing well in physical therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary based on a lack of current medical complexity and a lack of skilled nursing needs and intensive physical therapy needs. The enrollee's rehab needs can be safely met in a less intensive setting. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.
You asked the Plan to pre-approve the mechanism. You say that this is medically necessary. The Plan denied your request. The Plan says there is no neuromuscular diagnosis or severe arthritis in the hip or knee.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mechanism. Our reviewer says that the requested mechanism is not medically reasonable or necessary. Our physician reviewer found the documentation does not reveal objective imaging evidence of documentation of severe arthritis of the hip and/or a neuromuscular disease. The medical progress notes do include a seat lift in the course of treatment. The seat lift is not likely effect improvement in your condition or arrest or retard deterioration in your condition. The records do not show that you are totally incapable of standing from a chair in the home.
You have not had the back surgery yet. At this time, you can roll to the side to get out of the chair. There is no description or reference to your ability to ambulate. You do not meet the criteria for the seat lift mechanism. 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 mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vacuum erection device (L7900).
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that vacuum erection devices (L7900) are statutorily not covered. We looked at the file and Medicare rules. The requested device is never covered. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve a vacuum erection device (L7900).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for fluoroscopy services billed for date of service February 4, 2021.
You asked the Plan to pay for the fluoroscopy services. You say that the medical records were submitted to indicate the professional component and the claim should be paid. The Plan denied your request. The Plan says the code in dispute was reported for a participant in a clinical research program and was reported without a required modifier.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. We looked at the file and Medicare rules. The records provided only included a progress note from February 3, 2021. There are no medical records for the date of service that was billed. Without this documentation we are unable to determine whether payment is due, the amount of payment, or the validity of the absence/presence of a modifier. Based on this information, we decided that Medicare rules for coverage of the fluoroscopy services have not been met. Therefore, we decided that the Plan does not have to pay for fluoroscopy services billed for date of service February 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two (2) skilled nursing visits (CPT code G0299 X 2)
and eight (8) physical therapy visits (CPT code G0151 X 8) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says your records do not support the need for a skilled physical therapist to make more home
visits and your records do not support the need for a skilled nurse to make more visits.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 physician reviewer
found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs
(i.e. IVs, complex wound care, new ostomy). The enrollee does not have documented skilled therapy needs.
The enrollee is consistently ambulating more than 200 feet and lives in a facility with caregivers to assist the
enrollee. As such, the requested, ongoing, home health services are not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve two (2) skilled nursing visits (CPT code G0299 X 2) and eight (8) physical therapy visits
(CPT code G0151 X 8) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this device is helpful for treatment of the health problem.

The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. 

The requested device is statutorily not covered. Based on this information, we decided that Medicare rules for coverage of the device have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coflex lumbar interspinous decompression device (CPT
code(s): 22867 and 22868) for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says Coflex lumbar interspinous decompression device is unproven and not medically
necessary due to insufficient evidence of efficacy.
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 Coflex device is experimental. More research is needed to show safety and efficacy. High
failure rates have been reported with similar devices.
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 Coflex lumbar interspinous decompression device (CPT code(s): 22867 and 22868) for the
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception (97112) provided February 8, 2021.
You asked the Plan to pay for the therapeutic services. You say that you are filing an appeal for the procedure 97112, neuromuscular re-education. This is an independent procedure and should be paid. The Plan denied your request. The Plan says payment for this service was included under a more appropriate procedure code on the same date of service.
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 therapeutic services has a bundled relationship with code 98941 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 neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception (97112) provided February 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee does have a need for continued rehabilitation. The Plan denied your request. The Plan says the stay 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 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 surgical management of intracranial hemorrhage after a traumatic skull fracture. The enrollee was transferred to acute inpatient rehabilitation on September 23, 2021. Medical documentation signed October 8, 2021, states a recommendation for discharge to skilled nursing facility. 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, and 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded as 99152 provided on February 22, 2021.
You asked the Plan to pay for the anesthesia services. You say that this medical documentation supports the code as billed. The Plan denied your request. The Plan says the medical records do not support the code 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. In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the 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 intraservice time, patient age
5 years or older 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 anesthesia services. Our reviewer says that the documentation does not support the services as billed in this case. Our reviewer found the medical records provided do not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status,. Therefore, this 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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 99152 provided on February 22, 2021.