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

We decided that the Plan does not have to pre-approve an interlaminar/interspinous device for use with a spinal decompression surgery.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there needs to be additional studies to determine the effectiveness of this device compared to the widely-accepted and commonly performed spinal decompression with fusion.

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 these spacer devices are experimental. More research is needed to show safety and efficacy of the 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 an interlaminar/interspinous device for use with a spinal decompression surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you are being moved from the hospital and need to be sent to an inpatient facility. The Plan denied your request. The Plan says criteria for admission to the IRF setting have not been met.
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 you 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory panel rendered on July 7, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.

The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 

We looked at the file and Medicare rules. The file shows that the testing at issue was for 6 or more pathogens. 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 respiratory panel rendered on July 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the test strips and lancets 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 are not separately payable.

The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are bundled/excluded codes. 

We looked at the file and Medicare rules. Billed procedure codes A4253 (blood glucose test strips) and A4259 (lancets) have a status indicator of P and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the test strips and lancets rendered on May 4, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound examination of the abdomen (76705) provided on June 16, 2021.
You asked the Plan to pay for ultrasound 76705. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 76705 has a procedure-to-procedure (PTP) edit of 1 with code 93976 meaning that this code 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 ultrasound 76705 has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate line item without an appropriate modifier. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound examination of the abdomen (76705) provided on June 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodontal scaling and root planning (D4341) provided by a participating provider on June 9, 2021.
You asked the Plan to pay for periodontal scaling and root planning. You say that you would like the Plan to pay for these services. The Plan denied your request. The Plan says you do not have a dental rider; therefore, the requested non-routine dental services have been correctly denied.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planning (D4341) provided by a participating provider on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood glucose test or reagent strips for home blood glucose monitor and lancets provided on April 2, 2021.

You asked the Plan to pay for the blood glucose test or reagent strips for home blood glucose monitor and lancets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are 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. 

We find that CPT codes A4253 and A4259 are not supported in the medical record. Specifically, these codes have a status indicator of "P". A status indicator of P means that payment is always bundled into payment for other services not specified and no separate payment is made. Based on this information, we decided that Medicare rules for coverage of the blood glucose test or reagent strips for home blood glucose monitor and lancets have not been met. Therefore, we decided that the Plan does not have to pay for the blood glucose test or reagent strips for home blood glucose monitor and lancets provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous transluminal coronary angioplasty coded 92921 provided on April 14, 2021.

You asked the Plan to pay for the percutaneous transluminal coronary angioplasty. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code 92921 is percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery (List separately in addition to code for primary procedure). 

We find that CPT code 92921 is not supported in the medical record. Specifically, this code has a status indicator of "B". A status indicator of B means that payment is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the percutaneous transluminal coronary angioplasty have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous transluminal coronary angioplasty coded 92921 provided on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom upper arm prosthesis and accessories for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature shows that this device does not have proven benefit and is considered experimental and 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. At this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical
condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. 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 custom upper arm prosthesis and accessories for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex 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 overall, there is a lack of evidence to support interspinous spacer devices as safe and effective as the gold standard of surgical decompression.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says a Medicare Advantage Plan can require a trial of a preferred drug to treat a medical condition before covering another non-preferred drug.

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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found that in this case, the record indicates that the enrollee has osteoarthritis of the knee. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
You asked the Plan to pre-approve the additional non-emergency transportation. You say that you do not have a license or a vehicle and have no way to get to your appointments. The Plan denied your request. The Plan says you have exhausted the covered benefit of 22 trips that your plan allows.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of twenty-two (22) one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional non-emergency transportation (A0100).
Please Note: Our decision is based on the Plan contract that was active at the time of this request. The record shows that as of October 1, 2021 you became eligible under a new plan contract. You may submit a new appeal if you wish to see if the additional transportation can be covered under your new plan.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report rendered on March 27, 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 are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 93010 (EKG interpretation and report) and 25600 (closed treatment of distal radial fracture). Code 93010 is a column II code with a modifier indicator of 1 when billed with column I code 25600. Code 93010 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report rendered on March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pharmacogenetics panel rendered on June 3, 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 testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is covered when specific criteria 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee received pharmacogenetic testing for a diagnosis of recurrent moderate major depressive disorder. She was seen on June 3, 2021 for a routine follow-up visit and prescription refills. The documentation does not support that the enrollee has a diagnosis of cancer. The documentation does not show that the testing would impact the management of the enrollee's conditions as well as her outcomes. The testing was therefore 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 pay for the pharmacogenetics panel rendered on June 3, 2021.
Local Coverage Determination (LCD) L38435 referenced by the Plan is not valid for Part B Medicare and was not used in the MAXIMUS determination.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99202, 99212) and radiologic examination, spine, cervical (72040) provided April 16, 2021 to May 3, 2021.
You asked the Plan to pay for the office and diagnostic services. You say that you still have outstanding claims due to the issue you have with checks being issued to the provider and not the facility. You have been told numerous times that these checks will be reissued to the correct payor. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor. Requests for corrected claims to reprocess were not received as requested.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202, 99212) and radiologic examination, spine, cervical (72040) provided April 16, 2021 to May 3, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601, 99602) provided on January 7, 2021.
You asked the Plan to pay for home infusion therapy. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with valid codes.
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 codes 99601 and 99602 are not supported in the medical record. Specifically, these codes have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601, 99602) provided on January 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an overdenture (D5860).

You asked the Plan to pre-approve an overdenture. You say that you would like these replacement dentures. The Plan denied your request. The Plan says this service is not covered at this time.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an overdenture (D5860).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom knee orthosis (L1846).
You asked the Plan to pre-approve the custom knee orthosis. You say that the item is medically necessary. The
Plan denied your request. The Plan says the enrollee has not had recent injury or surgery to knee, exam
showing instability, and notes that support medical need for custom brace.
The Plan follows Medicare rules. Medicare rules say that if a custom fabricated orthosis is provided but the
medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the
custom fabricated orthosis will be denied as not reasonable and 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 custom knee orthosis. Our reviewer
says that the item is not medically necessary. Our physician reviewer found the enrollee has osteoarthritis of
the right knee; there is not a recent injury or surgery to the knee. The exam does not show instability and the
medical records do not support that a custom brace is medically necessary over a prefabricated brace.
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 custom knee orthosis have not been met. Therefore, we decided that the
Plan does not have to pre-approve the custom knee orthosis (L1846).