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

We decided that the Plan does not have to pre-approve use of Botox (botulinum toxin).
You asked the Plan to pre-approve Botox. You say that the enrollee is in a lot of pain and is having migraines due to bruxism. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because there is no documentation that the enrollee has tried and failed less risky or invasive first-line treatments.
The Plan follows Medicare rules. Medicare rules state that physicians should be familiar with and experienced in the use of botulinum toxins and utilize evidence-based medicine to select the appropriate drug and dose regimen for each patient's condition.
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 Botox. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found the record indicates that the enrollee has bruxism and failed Inderal therapy. There is no documentation that the enrollee has tried and failed less risky or invasive first-line treatments of bruxism such as dental devices/prosthodontics, self-care with relaxation, or cognitive behavior techniques. There is no documentation that the enrollee was referred to a dental or oral surgeon for evaluation. The enrollee does not meet the coverage indications for Botox. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Botox (botulinum toxin).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid provided on November 24, 2020.
You asked the Plan to pay for the hearing aid. You say that this provider is on the list of approved hearing
centers. You say that you are living on a fixed income and would like to be reimbursed as much as possible.
The Plan denied your request. The Plan says hearing aids received from an out-of-network provider are not
covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when they are received from the Plan's designated hearing vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for the
hearing aid provided on November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve liquid sclerotherapy (36468) for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your request is not medically necessary because the records do not show a CEAP clinical classification, a revised VCSS, or documentation that supports signs and/or symptoms that interfere with activities of daily living and/or quality of life.

The Plan follows Medicare rules. Medicare rules say that liquid sclerotherapy can be covered if the LCD criteria have 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 these services. Our reviewer says that these services are not medically reasonable and necessary for the enrollee in this case. There is no clear documentation that the patient's symptoms are activity or mobility limiting and the required venous severity scores are not provided. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for 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 liquid sclerotherapy (36468) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided on March 3, 2021, to March 14, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the home health services. You say that there were no in-network rehabilitation facilities available. You say this was an emergency. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the home health services provided on March 3, 2021, to March 14, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on May 6, 2021.

You asked the Plan to pay for a magnetic resonance angiography. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says this is 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. In this case, we have confirmed that code 70544 has a bundled relationship with code 70551 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a magnetic resonance angiography (70544) provided on May 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of breast localization device(s), coded 19285,
and the diagnostic mammography, coded 77065, provided on January 6, 2021.

You asked the Plan to pay for the placement of breast localization device(s) and the diagnostic mammography.
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.

We find that CPT codes 19285 and 77065 are not supported in the medical record. Specifically, these codes
were billed with a GZ modifier. When a GZ modifier is submitted a complex medical review is not performed
and the claim is automatically denied. Therefore, we find the Medicare rule of payment of codes 19285 and
77065 for January 6, 2021, claim has not been met. Based on this information, we decided that Medicare rules
for coverage of the placement of breast localization device(s) and the diagnostic mammography have not been
met. Therefore, we decided that the Plan does not have to pay for the placement of breast localization device(s),
coded 19285, and the diagnostic mammography, coded 77065, provided on January 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health services from October 19, 2021, onward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that you meet the criteria for continued care at the inpatient level. The Plan denied your request. The Plan says as of October 19, 2021, you no longer met the criteria for inpatient psychiatric services and could safely be treated in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued inpatient psychiatric care beyond the dates in question appears appropriate in this case. Our physician reviewer found that you were admitted to an acute inpatient psychiatric hospitalization on October 11, 2021 with Bipolar Disorder, Current Episode Manic, Severe with Psychotic Features, Now Called, Severe and Major Neurocognitive Disorder Most Likely Due to Alcohol Use. Based upon review the records provided it was not expected that you would improve in a reasonable period of time for the dates in question as you did not have suicidal or homicidal ideation noted and no auditory or visual hallucinations. You did not show any abnormal behaviors or any symptoms which would require acute treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have dangerousness to self or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Based upon review the records provided for the admission do not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 19, 2021 forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health services from October 19, 2021, onward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection procedure for cholangiography provided on April 27, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the injection procedure for cholangiography. You say that this procedure code does not require authorization for an outpatient hospital. You say the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for an injection procedure for the cholangiography provided on April 27, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a
need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99213) and the x-ray exam of the hip
(73502) rendered by the OON provider on October 22, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were 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 must 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the office visit (99213) and the x-ray exam of the hip (73502) rendered by the
OON provider on October 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve the drug. You say that this is medically necessary based on a diagnosis of
chronic kidney disease, unspecified. The Plan denied your request. The Plan says the information provided
does not show that the policy requirements have been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe
and effective and otherwise 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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found the information
provided does not show that the policy requirements have been met. The requirements support the use of
Aranesp for anemia due to chronic kidney disease when the hemoglobin (a test of your red blood cells) is less
than 11 g/dL or hematocrit is less than 33% within the last 30 days. The requirement(s) not met are: The
records show that the hemoglobin is 11.5 g/dL. The records show that the hematocrit is 34.7%. The review has
determined that the documentation does not support that the Aranesp is medically reasonable, necessary, safe,
or effective.
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 Aranesp.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 16 additional physical therapy visits in the home.
You asked the Plan to pre-approve the home health services. You say that the enrollee needs additional home health physical therapy. The Plan denied your request. The Plan says the requested visits are not medically reasonable or necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer says that the additional 16 physical therapy visits in your home are not medically necessary. Our physician reviewer found the provided documentation does not support that the enrollee requires additional skilled rehabilitation (rehab) services to provide treatment that is medically necessary. The reviewer found that the enrollee does not require additional skilled rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The reviewer found that the enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested home health services 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 home health services have not been met. Specifically, the file does not support that the enrollee requires additional skilled rehabilitation services to provide treatment. Therefore, we decided that the Plan does not have to pre-approve 16 additional physical therapy visits in the home.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on January 23, 2021.
You asked the Plan to pay for the advance care planning 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 99497 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted did not discussion between the provider and the enrollee, along with family members, or surrogates, regarding eventual end-of-life decisions and preferences; therefore, the Advance Care Planning service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on January 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on May 10, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the hospital outpatient clinic visit. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.

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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the hospital outpatient clinic visit provided on May 10, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an over the bed table for the enrollee.

You asked the Plan to pre-approve an over the bed table. You say that the enrollee had a stroke and needs this table for daily use. The Plan denied your request. The Plan says over the bed tables are not covered by Medicare.

The Plan must follow Medicare rules. Medicare does not cover self-help devices. An over the bed table is a self-help device. While this item may be appropriate for the enrollee's use, it is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve an over the bed table for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 7, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on April 7, 2021.