Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve outpatient mental health services with a non-Medicare enrolled provider.  You asked the Plan to pre-approve the services. The Plan denied your request. The Plan says this is not an eligible provider.  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 pre-approve outpatient mental health services with a non-Medicare enrolled provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code A9279 billed for dates of service April 1, 
2021, to May 1, 2021.
You asked the Plan to pay for procedure code A9279. You say that you have provided medical records to 
support payment. The Plan denied your request. The Plan says this code is not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that codes billed that have a status indicator of "I" are 
not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 
We find that CPT code A9279 has a status indicator of "I". Based on this information, we decided that 
Medicare rules for coverage of procedure code A9279 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code A9279 billed for dates of service April 1, 2021, to May 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transurethral waterjet ablation 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 the request cannot be approved 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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee does not have a covered indication for this request. Specifically, the prostate volume is not
between 30-150cc, a flow rate of less than 15 mL/s was not provided, and an International Prostate Symptom
Score (IPSS) 12 or more was not provided.
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 transurethral waterjet ablation for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on October 4, 2021.
You asked the Plan to pay for the services. You say that the services were billed correctly and should be paid for. The Plan denied your request. The Plan says the records are insufficient to support payment for the services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. 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 pain management services (procedure code 62320) provided to the enrollee on October 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oncotype DX Breast Cancer Assay.
You asked the Plan to pre-approve Oncotype DX Breast Cancer Assay. You say that the requested Oncotype DX Breast Cancer Assay is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested Oncotype DX Breast Cancer Assay.
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 Oncotype DX Breast Cancer Assay. Our reviewer says that the enrollee does not meet criteria for the requested Oncotype DX Breast Cancer Assay. Our physician reviewer found the enrollee is with T2N2a breast cancer, ER+, her 2 neu-. The review shows that the enrollee has 4 involved lymph nodes. Adjuvant chemo is indicated in this case. The requested Oncotype DX Breast Cancer Assay is 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 Oncotype DX Breast Cancer Assay have not been met. Therefore, we decided that the Plan does not have to pre-approve Oncotype DX Breast Cancer Assay.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular neve blocks.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is
no medical evidence that these nerve blocks are safe and effective.
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 requested services. Our physician
reviewer found that the enrollee has a history of knee pain. Genicular nerve blocks and radiofrequency
ablations are considered investigational and not medically necessary for the treatment of chronic knee pain.
Therefore, the requested block is 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 the requested services have not been met. Therefore, we decided that the Plan
does not have to pre-approve genicular neve blocks.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the transfer of a specimen from an office to a laboratory provided on August 25, 2021, billed with code 99000.
You asked the Plan to pay for the specimen transfer fee as billed. You say that this claim should be paid. The Plan denied your request. The Plan says no separate payment is made for code 99000.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
CPT code 99000 has a status indicator of "B" on the Physician Fee Schedule, meaning that payment is always bundled into payment for other services. Based on this information, we decided that Medicare rules for coverage of the specimen transfer fee as billed have not been met. Therefore, we decided that the Plan does not have to pay for the transfer of a specimen from an office to a laboratory provided on August 25, 2021, billed with code 99000.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the "Up Walker."
You asked the Plan to pre-approve the walker. You say that you walk about 10 miles a day with a walker, and use it daily. The Plan denied your request. The Plan says there is no documentation from a medical provider justifying the medical necessity of such an item.
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 walker. Our reviewer says that the requested walker is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has chronic medical conditions. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 walker have not been met. Therefore, we decided that the Plan does not have to pre-approve the "Up Walker."
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services provided to the enrollee on June 7, 
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this was submitted past timely filing limits.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the services was not filed until August 26, 2021. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for emergency room services provided to the enrollee on June 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that the requested compression stockings are medically necessary. The Plan denied your request. The Plan says the requested compression stockings are not covered by Medicare.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary.
The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 
The records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for medical equipment billed with procedure code E0748 for 
date of service May 17, 2021.
You asked the Plan to pay for procedure code E0748. You say that the patient never advised you that they were 
in a skilled nursing facility. The Plan denied your request. The Plan says this enrollee was in a covered skilled 
nursing facility stay at the time this equipment was provided, so no separate payment can be made. The Plan 
has confirmed that this patient was in a covered stay from May 7, 2021, to May 21, 2021.
The Plan must follow Medicare rules. The rules say that when durable medical equipment (DME) is furnished 
for use in a skilled nursing facility during a covered Part A stay, no separate payment is made for the DME, 
since the DME is already included in the payment that the nursing facility receives for the covered stay itself. 
Records show that procedure code E0748 was provided while the enrollee was in a covered skilled nursing 
facility stay. Therefore, we decided that the Plan does not have to pay for medical equipment billed with 
procedure code E0748 for date of service May 17, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that the requested continuation of SNF care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for continued SNF care. 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 the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with hip fracture and open reduction internal fixation (ORIF), seizures, osteoporosis, and coronary artery disease (CAD). From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. She was treated for pain. Her lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy. The enrollee was at a standby assist to contact guard assist level for functional mobility including gait to 200 feet with a rollator walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test socket, below knee (CPT code L5620), below knee, 
acrylic socket (L5629), below knee, total contact (L5637), below knee, flexible inner socket, external frame 
(L5645), below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone 
gel, elastomeric or equal, for use with locking mechanism (L5673), below knee, removable medial brim 
suspension (L5972), and multiaxial ankle with swing phase active dorsiflexion feature (L5968).
You asked the Plan to pre-approve the items. You say that you want the prosthesis approved in order to do 
daily tasks. The Plan denied your request. The Plan says the Medicare rules have not been 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 items. Our physician reviewer 
found there is no indication you are a K2 ambulator or that there is any special circumstance to support the 
need for a below the knee acrylic socket. There is no current documentation that supports the need for a 
specialized socket.
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 items have not been met. Therefore, we decided that the Plan does not have 
to pre-approve test socket, below knee (CPT code L5620), below knee, acrylic socket (L5629), below knee, 
total contact (L5637), below knee, flexible inner socket, external frame (L5645), below knee/above knee, 
custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use 
with locking mechanism (L5673), below knee, removable medial brim suspension (L5972), and multiaxial 
ankle with swing phase active dorsiflexion feature (L5968).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance angiography (MRA) scan of the 
abdomen (74185).
You asked the Plan to pre-approve an MRA of the abdomen. You say that the requested service is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage for 
the requested service have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRA of the abdomen. Our reviewer 
says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer 
found that there was not significant documentation provided to justify the requested service. There was no 
reason given why a computed tomography (CT) scan would not give the same information.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the abdomen have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance angiography (MRA) scan of the abdomen (74185).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gradient compression sleeve identified with code A6530.
You asked the Plan to pre-approve the compression sleeve. You say that the sleeve is to prevent infections and swelling. The Plan denied your request. The Plan says the sleeve does not primarily serve a medical purpose.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. We looked at the file and the rules. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve a gradient compression sleeve identified with code A6530.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 additional transforaminal epidural steroid injections 
(64484).
You asked the Plan to pre-approve 2 additional transforaminal epidural steroid injections. You say that the 
requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules 
for coverage for the requested services have not been met.
The Plan must follow Medicare rules. Medicare rules say that no more than 2 TFESIs should be performed at a 
single setting (e.g., single level bilaterally or two levels).
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of 2 additional transforaminal epidural steroid injections have not been met. Specifically, the case 
record shows that the Plan has approved TFESIs at a single level bilaterally.
Additional TFESIs are not covered. Therefore, we decided that the Plan does not have to pre-approve 2 
additional transforaminal epidural steroid injections (64484).
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 nausea and abdominal pain. 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, in an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 an oximeter.
You asked the Plan to pre-approve an oximeter. You say that an oximeter is medically necessary because you
had Covid 19. The Plan denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules specifically stated an oximeter is not covered. This item is available to the public
and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not
have to pre-approve an oximeter.