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

We decided that the Plan does not have to pre-approve a third level of cervical facet joint injections with
imaging.
You asked the Plan to pre-approve a third level of cervical facet joint injections with imaging. You say that the
enrollee is in severe pain. The Plan denied your request. The Plan says coverage is limited to no more than 2
levels per spinal region, per injection session.
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region. Three or four level procedures are only covered in unique circumstances
and when medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a third level of cervical facet joint
injections with imaging. Our reviewer says that the criteria for coverage have not been met. Our physician
reviewer found two levels bilaterally have been approved. If there is a persistent area of pain, then additional
diagnostic blocks can be considered. At this point only 2 levels bilaterally are needed. It has not been
demonstrated that there are unique circumstances which require a third level at this time.
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 third level of cervical facet joint injections with imaging have not been met.
Therefore, we decided that the Plan does not have to pre-approve a third level of cervical facet joint injections
with imaging.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on June 1,
2021.
You asked the Plan to pay for the critical care services. 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 supported by the documentation.
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 99291 is critical care, evaluation and management of the
critically ill or critically injured patient; first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted
did not support a critical care visit of 30-74 minutes was performed on the billed date of service. The
documentation does not include the time spent providing this service. Based on this information, we decided
that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the
Plan does not have to pay for the critical care services coded 99291 provided on June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the panoramic x-ray (D0330), and oral photographic images (D0350 x 4) provided on September 22, 2021.  You asked the Plan to pay for the dental service. You say that you were advised the x-rays would be covered. You also say that you feel that you should not be responsible for this bill. The Plan denied your request. The Plan says panoramic film or diagnostic x-rays up to 1 per year. The Plan says that the frequency limit has been exceeded. The Plan also says that oral photographic images are not listed as covered services.  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 panoramic x-ray is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a diagnositc x-ray that you received on the same date of service thus exhausting the benefit. Additionally, the oral photographic images are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), and oral photographic images (D0350 x 4) provided on September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for anesthesia services (S1015, S8301, 99199) provided July 30, 2021.  You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT codes S1015, S8301, and 99199 are not supported in the medical record. Specifically, CPT codes S1015, & S8301 have a status of "I" per the National Physician Fee Schedule and are invalid for Medicare payment. CPT code 99199 is included in payment to the facility. 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 anesthesia services (S1015, S8301, 99199) provided July 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (procedure code 95908, 95886) provided to the
enrollee on August 4, 2021.
You asked the Plan to pay for the services. You say that you would like reconsideration based on records
submitted. The Plan denied your request. The Plan says the documentation does not support the services 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 the denied codes is:
CPT 95908:
Nerve conduction studies; 3-4 studies
CPT 95886:
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three
or more nerves or four or more spinal levels (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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found in terms of CPT 95908, the
documentation does not describe patches placed directly over a muscle for sensory testing, or motor point of a
specific muscle in motor conduction testing. This procedure cannot be confirmed. For CPT 95886, the
description of the code shows that this procedure is performed with nerve conduction studies. In this case,
nerve conduction studies cannot be verified, therefore this procedure would not be covered.
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 services have not been met. Therefore, we decided that the Plan does not
have to pay for the services (procedure code 95908, 95886) provided to the enrollee on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacroiliac joint injection services.

You asked the Plan to pre-approve sacroiliac joint injection services. You say that the clinical documentation provided supports the need for the requested injection services. The Plan denied your request. The Plan says the notes do not show that specific movements worsened the enrollee's pain. The Plan says that the injection services being requested are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve sacroiliac joint injection services. Our reviewer says that sacroiliac joint injection services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is a lack of documentation of the physical exam and imaging that supports the diagnosis of Sacroiliitis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of sacroiliac joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac joint injection services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 provided on March 18, 2021.
You asked the Plan to pay for the targeted genomic sequence analysis panel. 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 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 documentation did not include documentation to support that this service would likely impact therapeutic decision-making in the clinical management of the enrollee. This means the targeted genomic sequence analysis panel 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 the targeted genomic sequence analysis panel coded 81455 provided on March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radio frequency ablation (RFA) services.

You asked the Plan to pre-approve RFA services. You say that this is the last resort for pain relief. You say that surgery is not an option. The Plan denied your request. The Plan says there is insufficient scientific evidence in the medical literature that this treatment is effective for the enrollee's condition.

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 RFA services. Our reviewer says that RFA of the lateral sacral branches is not considered medically reasonable and necessary in this case. Our physician reviewer found these services are considered experimental and investigational due to a wide variation in efficacy reported in medical literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radio frequency ablation (RFA) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve office visit services with an out of network (OON) surgical
oncologist.
You asked the Plan to pre-approve the OON office visit services. You say that the enrollee needs to receive
treatment closer to her home and at a location she is familiar with. The Plan denied your request. The Plan says
that they have network providers who can treat the enrollee.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is
considered accessible to an enrollee if contract providers are available within reasonable distance and travel
time from the enrollee's home. The plan contract says that enrollees must use contract providers.
The requested provider is a non-contract provider. The requested provider is a surgical oncologist and the
Plan's referral was to a provider who was 76 miles from the enrollee's home address. We were able to confirm
that the contract provider the Plan has referred the enrollee to is not located within reasonable distance and
travel time from the enrollee's home. Under Medicare rules, this means that contract provider is not accessible
to the enrollee. Therefore, we decided that the Plan has to pre-approve office visit services with the requested
out of network (OON) surgical oncologist.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70544) provided September 13, 2021.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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 70544 is a column II code to column I code 70553. 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 radiology services (70544) provided September 13, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve the inpatient hospital admission. You say that the records provided support the need for an inpatient admission during the enrollee's scheduled surgery. The Plan denied your request. The Plan says that the arthroplasty services have been approved as outpatient and there is no need demonstrated for an inpatient admission.
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 the inpatient hospital admission. Our reviewer says that the documentation supports that the criteria for an inpatient admission are met in this case. Our physician reviewer found the enrollee was being treated for unilateral primary osteoarthritis, right knee. She is planned to undergo a robotic assisted total knee arthroplasty on the right. The documentation indicates a past medical history to include diabetes mellitus type II, sleep apnea, anemia, depressive disorder, gastroesophageal reflux disease; hyperlipidemia; hypertension; iron deficiency anemia secondary to inadequate dietary iron intake; and a stroke. There are noted significant co-morbidities that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. Therefore, the record does show that at the time of the request for an inpatient admission, the requesting physician reasonable expected that the enrollee's necessary hospital 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 the inpatient hospital admission have been met. Therefore, we decided that the Plan has to pre-approve an inpatient hospital admission.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the ThyGeNext thyroid oncogene panel provided on June 28, 2021.
You asked the Plan to pay for the ThyGeNext thyroid oncogene panel. You say that this was felt to be
medically necessary by the enrollee's treating physician to evaluate the risk of malignancy. The Plan denied
your request. The Plan says that this is a screening test that is noncovered by Medicare. Plan-directed care
cannot override this denial since there is no benefit for this test.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The plan follows these rules.
The enrollee was referred for the ThyGeNext thyroid oncogene panel by a contract provider. The file does not
show that the plan provided notice that the ThyGeNext thyroid oncogene panel would not be covered. We find
that the Plan's determination that this is an excluded screening test is invalid. Screening means that the test is
performed in the absence of signs/symptoms of disease. This enrollee had a thyroid nodule which underwent
fine needle aspiration and showed mild atypia in the cells. This means the testing was diagnostic in nature. We
found no other Medicare rule which clearly excludes this testing from coverage. Under Medicare rules, this
means the ThyGeNext thyroid oncogene panel is considered approved by the plan. Therefore, we decided that
the Plan has to pay for the ThyGeNext thyroid oncogene panel provided on June 28, 2021.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic services and drugs/vitamins provided on June 8, 2021.
You asked the Plan to pay for therapeutic and drug services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says these services are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by or under the direct supervision of a physical therapist in private practice; or by, or incident to the services of a nurse practitioner (NP) or physician assistance (PA) only when that NP/PA may perform physical therapy services under State Law. Medicare rules say that claims for compounded drugs must be submitted using a compounded drug not otherwise classified code.
We looked at the file and Medicare rules. 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 therapeutic and drug services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic services and drugs/vitamins provided on June 8, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy service (90837) rendered by the out-of-network (OON) provider on July 14, 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 psychotherapy service (90837) rendered by the out-of-network (OON) provider on July 14, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on  You asked the Plan to pay for the emergency department visit. 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 supported by the documentation.  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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.  We find that CPT code 99285 is not supported in the medical record. Specifically, the submitted documentation supports one unit of this code, which was already approved and paid by the Plan. There is no additional documentation supporting additional services which were billed. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on