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

 We decided that the Plan does not have to pay for the infusion pump refill kit provided on October 22, 2020.  You asked the Plan to pay for the services provided. You say that the medical records support the billed services. The Plan denied your request. The Plan says no separate payment is made.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    We looked at the file and the rules. We find that the payment for CPT code A4220 is packaged into payment for other services. There is no separate payment for this service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump refill kit provided on October 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a rhytidectomy procedure (15826).  You asked the Plan to pre-approve a rhytidectomy procedure. You say that the requested care is necessary to restore damage from a fall. The Plan denied your request. The Plan says the requested procedure is not a covered benefit because the procedure is cosmetic.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    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 a rhytidectomy procedure. Our reviewer says that the requested procedure is not medically reasonable and necessary in this case. Our reviewer found that you suffered facial trauma and have a persistent soft tissue defect. The record does not indicate a functional deficit. The requested procedure is cosmetic in nature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a rhytidectomy procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a rhytidectomy procedure (15826).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genetic testing for Parkinson's disease, Alzheimer's disease, and Huntington's disease.  You asked the Plan to pre-approve genetic testing services. You say that these services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested genetic testing is not medically reasonable and necessary at this time.  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 genetic testing services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case the member is noted to have cognitive impairment in the setting of symptoms suggestive of parkinsonism. Their provider suspects a possible genetic etiology for their symptoms.  However, the member's presentation is not readily consistent with any well-defined genetic disorders/syndromes. It was not clear from the notes provided for review as to how the requested testing would be beneficial in ongoing patient evaluation and management services. Nor is it clear how said testing would be effective in changing the course of treatment for the member's condition. In as much in this context, the use of genetic testing would be of unproven clinical utility. As such the requested test cannot be determined to be reasonable 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 genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for Parkinson's disease, Alzheimer's disease, and Huntington's disease.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a catheter placement (36215) provided May 27, 2021.

You asked the Plan to pay for the catheter placement. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.

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 36215 is not supported in the medical record. Specifically, the procedure report does not include documentation of selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch. Based on this information, we decided that Medicare rules for coverage of the catheter placement have not been met. Therefore, we decided that the Plan does not have to pay for a catheter placement (36215) provided May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for critical care (99292) provided on April 21, 2021.  You asked the Plan to pay for critical care. You say that this is supported in the records. The Plan denied your request. The Plan says this cannot be paid as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code critical care is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99292) provided on April 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation.  You asked the Plan to pre-approve these services. You say that this procedure worked well for back pain, so you would like to try it for your hip. The Plan denied your request. The Plan says that there has been insufficient evidence to show that this procedure is safe and effective in the treatment of your lower back pain.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. This is considered experimental/investigational because of the wide variation in efficacy reported in the peer reviewed literature. Our physician reviewer found that your condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nail services (11721) provided on April 26, 2021.

You asked the Plan to pay for debridement of nail services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says the documentation supports one unit of 11721 which was approved, but not an additional service.

The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. 

We find that CPT code 11721 is not supported in the medical record. Specifically, the record indicates that this is an exact duplicate of another claim that has been processed and paid. The documentation provided does not support that an additional unit of 11721 was performed beyond what the Plan has already paid. Based on this information, we decided that Medicare rules for coverage of debridement of nail services have not been met. Therefore, we decided that the Plan does not have to pay for debridement of nail services (11721) provided on April 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services billed with principal diagnosis code J69.0, provided on June 16 - June 19, 2020.

You asked the Plan to pay for the inpatient hospital services. You say that pneumonitis due to inhalation of food and vomit is a valid principal diagnosis based on the documentation within the medical record. The Plan denied your request. The Plan says the enrollee developed respiratory symptoms after admission and aspiration pneumonia was not the reason for admission.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with principal diagnosis code J69.0, defined as pneumonitis due to inhalation of food and vomit. 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 the inpatient hospital services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found per discharge summary and progress note, the enrollee was admitted for suspected food impaction following ingestion of shredded chicken. The discharge summary also stated that aspiration pneumonia was not detected or noted until evaluation post esophagogastroduodenoscopy (EGD.) The enrollee underwent EGD which revealed impacted shredded chicken at the middle third of the esophagus and it was successfully dis-impacted by gastroenterologist. The enrollee developed respiratory symptoms after admission. Aspiration pneumonia was not the reason for admission per documentation not showing the condition present upon admission. Over the course, the enrollee was admitted for further evaluation and treatment was directed towards the diagnosis of foreign body aspiration in esophagus and it was the condition that occasioned the enrollee's admission requiring the most resources and focus of care. The review has determined that the principal diagnosis billed was not supported by the medical records provided.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services billed with principal diagnosis code J69.0, provided on June 16 - June 19, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) assay provided on June 11, 2021.  You asked the Plan to pay for thyroid stimulating hormone (TSH) assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The thyroid stimulating hormone (TSH) assay at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for thyroid stimulating hormone (TSH) assay provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214) provided on September 14, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that Medicare does not require authorization. The Plan denied your request. The Plan says authorization is required for out-of-network 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 had network providers available who could have provided 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 (99214) provided on September 14, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for office visit with lab services (99215, 36415, 83036, and 85025) provided on September 7, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for office visit with lab services. You say that these services were medically necessary for the enrollee's condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.  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 had network providers available who could have provided 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 office visit with lab services (99215, 36415, 83036, and 85025) provided on September 7, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac (SI) joint arthrodesis 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 this is denied as 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 minimally invasive SI joint fusion is investigational for low back pain. There is no documented evidence of SI joint instability, fracture or lesion. 

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 sacroiliac (SI) joint arthrodesis for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0425 and A0428) provided on July 20, 2021.  

You asked the Plan to pay for the non-emergency ambulance transportation. You say that you have very bad knees because your cartilage is gone, and your left knee is very bad. You also say that you have Atrial fibrillation, cancer, and you are in pain a lot. The Plan denied your request. The Plan says there is no documentation that you are unable to ambulate nor unable to sit in a chair or wheelchair. The Plan also says that the criteria are not met.  

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   

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 the non-emergency ambulance transportation. Our reviewer says that the documentation did not support that the ambulance transport on July 20, 2021 was medically reasonable and necessary. Our physician reviewer found the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for you on July 20, 2021. Our reviewer also found that you did not need the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on this date of service.   

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 non-emergency ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transportation (A0425 and A0428) provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and refraction services received on July 7, 2021.

You asked the Plan to pay for the eye exam and refraction services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers vision services when received from an Select Network optical provider. 

We looked at the file and the Plan's rules. Review of the file shows that you did not receive these vision services from an Select Network optical provider. Based on this information, we decided that the Plan's rules for coverage of the eye exam and refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the eye exam and refraction services received on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transforaminal epidural injections (TFESIs) represented by codes 64480-RT and 64480-LT.  You asked the Plan to pre-approve TFESIs. You say that the medical records provided support the need for the injection services in dispute. The Plan denied your request. The Plan says it is not medically necessary to perform TFESIs at more than 2 nerve root levels during the same session.  The Plan follows Medicare rules. Medicare rules say that it is not considered medically reasonable and necessary to perform TFESIs at more than two nerve root levels during the same session.  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 TFESIs. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of thoracic back pain with radiculopathy.  The pain is described as severe spasms, and at times will "lockup," restricting movement.  The imaging demonstrates solid fusion L3-L5, L5-S1, as well as mild disc bulging at C5-6 and T8-9.  This is a pre-service request for bilateral transforaminal epidural steroid injections (TFESIs) at T9 and T10 levels, CPT codes 64479-RT, LT and 64480-RT, LT. Of note, CPT codes 64479-RT and 64479-LT have been approved by the Plan. Bilateral TFESIs at one level are reasonable and medically necessary for the evaluation and treatment of the enrollee. The review indicates that the requested 2nd level nerve root injection services (CPT codes 64480-RT and 64480-LT) are not 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 the denied TFESIs have not been met. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural injections (TFESIs) represented by codes 64480-RT and 64480-LT.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after December 24, 2021.  

You asked the Plan to pre-approve SNF care. You say that SNF care continues to be medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for SNF care have not been met.  

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 that as of December 24, 2021, the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of December 24, 2021. The member did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved; however, his functional improvement had plateaued by December 24 and he did not require any further inpatient skilled rehab services. The member's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of December 24, the member required custodial 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care after December 24, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a CT scan of the head or brain (70450) provided on October 15, 2020.  You asked the Plan to pay for a CT of the head or brain. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CT of the head or brain have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a CT scan of the head or brain (70450) provided on October 15, 2020.