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

 We decided that the Plan does not have to pre-approve deep brain stimulation. 
 
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 records show moderate, not advanced, Parkinson's disease. 
 
The Plan must follow Medicare rules. Medicare rules say that deep brain stimulation is covered for essential 
tremor or Parkisonian tremor only under certain conditions. 
 
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 that in this case, the records provided for review did not readily demonstrate advanced idiopathic 
Parkinson's disease based on the UPDRS part III motor subscale. Likewise, it cannot be determined that you 
had L-dopa responsive with clearly defined "on" periods. Given that these two requirements were not satisfied 
the criteria for coverage would not be met and this request would not meet the requirements in the NCD. 
 
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 deep brain stimulation.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and the annual wellness visit (G0439) 
rendered by the out-of-network (OON) provider on June 9, 2021. 
 
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 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 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 (99214) and the annual wellness visit (G0439) rendered by the 
out-of-network (OON) provider on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychological or neuropsychological test administration 
and scoring by a physician or other qualified health care professional, two or more tests, any method; first 30 
minutes (96136) rendered by the out-of-network (OON) provider on June 21, 2021. 
 
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 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 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 psychological or neuropsychological test administration and scoring by a 
physician or other qualified health care professional, two or more tests, any method; first 30 minutes (96136) 
rendered by the out-of-network (OON) provider on June 21, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (CPT code 90837) provided to the enrollee from June 3, 2021, through June 10, 2021, by an out-of-network provider.

You asked the Plan to pay for the out-of-network psychotherapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 the psychotherapy services (CPT code 90837) provided to the enrollee from June 3, 2021, through June 10, 2021, by an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT visits are not medically
necessary. The Plan denied your request. The Plan says four (4) additional PT visits as not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 four (4) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found that there is no change in the enrollee's condition
with 24 visits and she needs to focus on a home exercise program. The records do not demonstrate that the
unique skills of a professional therapist are required to safely and effectively provide treatment, that the
services can be safely and effectively performed only by a therapist, or for physical therapy and occupational
therapy, by or under the supervision of a therapist. There is no documentation provided to support that the
requested services are part of a maintenance program, are the specialized skill, knowledge and judgment of a
qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current
condition or to prevent or slow further deterioration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of four (4) additional PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve four (4) additional PT visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the upper respiratory testing services provided on October 29, 2020. You asked the Plan to pay for the testing services. You say that services were performed in good faith. The Plan denied your request. The Plan says genetic screening testing is not a Medicare 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.  We looked at the file and the rules. In this case, there are insufficient records to show that each test was ordered due to signs and symptoms of the enrollee. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the upper respiratory testing services provided on October 29, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an esophagogastroduodenoscopy (43236) provided on April
30, 2021.

You asked the Plan to pay for an esophagogastroduodenoscopy. You say that this was billed correctly. The
Plan denied your request. The Plan says the use of modifier -59 is not supported.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the
service billed with the modifier indicates a distinct procedural service.

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural
service from the billed column I code, 43255. Specifically, the records do not show that this service was
performed in a separate encounter, surgery, or site. Based on this information, we decided that Medicare rules
for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does
not have to pay for an esophagogastroduodenoscopy (43236) provided on April 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Boostrix tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccination.  You asked the Plan to pre-approve TDAP vaccination. You say that you are requesting a 1-time Boostrix injection. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this vaccination is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide TDAP vaccination. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to TDAP vaccination. Therefore, we decided that the Plan does not have to pre-approve a Boostrix tetanus, diphtheria toxoids, and acellular pertussis (TDAP) vaccination.   Benefits for TDAP vaccination may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a gastric-band adjustment (S2083) provided on September 17, 2020.  You asked the Plan to pay for a gastric-band adjustment. You say that the Plan has previously paid for the same procedure. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. Code S2083 has a status indicator of "I" on the Physician Fee Schedule. This means that it is "invalid for Medicare billing purposes." Based on this information, we decided that Medicare rules for coverage of a gastric-band adjustment have not been met. Therefore, we decided that the Plan does not have to pay for a gastric-band adjustment (S2083) provided on September 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary cardiovascular risk assessment testing provided on June 20, 2021.  You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the service is 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.  We looked at the file and the rules. It appears that the testing was ordered by an unsolicited outreach telephone call to the enrollee, The records do not show that the testing was ordered by the enrollee's treating physician for a specific medical problem. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular risk assessment testing provided on June 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (hereditary assessment for cardiac conditions) provided to the enrollee on April 12, 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 experimental or investigational services are not covered.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found review indicates that there is no Medicare benefit for screening cardiovascular risk assessment testing for asymptomatic patients. Screening asymptomatic patients for cardiovascular risk is not a covered Medicare benefit.  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 pay for laboratory services (hereditary assessment for cardiac conditions) provided to the enrollee on April 12, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ertapenem (J1335) and intravenous infusion, for therapy, prophylaxis, or diagnosis (96953).

You asked the Plan to pre-approve Ertapenem infusions. You say that the requested drug is not FDA-approved for the enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug is medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Ertapenem infusions. Our reviewer says that Ertapenem infusion is not medically necessary. Our physician reviewer found the Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The reviewer found that the Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The reviewer found that the elements of the coverage criteria are not satisfied. Therefore, the reviewer found that the request for Ertapenem infusion is not medically reasonable or 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 Ertapenem infusions have not been met. Specifically, the file shows that the requested drug is not approved by the FDA for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Ertapenem (J1335) and intravenous infusion, for therapy, prophylaxis, or diagnosis (96953).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic procedures provided on May 20, 2021.  You asked the Plan to pay for diagnostic procedures. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the records submitted do not support the codes 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 code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The CPT Code Manual definition of code 95886 is 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 diagnostic procedures. Our reviewer says that these codes do not meet the Medicare criteria for payment. Our reviewer found the technical report documents "real-time" monitoring; therefore, code 95957 would not be used to report continuous monitoring.  There is a more appropriate code to report for "real-time monitoring', and any additional testing would be included in the appropriate code to report for intraoperative monitoring. The technical report does not include nerve conduction studies to include measurement of amplitude, latency and conduction velocity.  Documentation support "screw stimulation", which is not report with nerve conduction study code 95908. The technical report does not support neuromuscular junction testing code 95937. Technical report is reporting this procedure for Train of Four which would be included in the primary monitoring code, and not reported separately. Nerve conduction studies are included in the description of code 95886, as nerve conduction studies were not documented, code 95886 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 diagnostic procedures have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic procedures provided on May 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lumbar spinal surgery for the enrollee.  You asked the Plan to pre-approve the surgery. You say that physical therapy has been tried without lasting benefit. The Plan denied your request. The Plan says the notes indicate a history of smoking.  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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there must be appropriate documentation of smoking cessation for 12 weeks prior to spinal fusion surgery. Smoking is a contraindication to spine fusion surgery.  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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar spinal surgery for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve custom foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the enrollee requires the custom foot orthotics. 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.    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 custom foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services (99214) provided on March 25, 2021.  You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.  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 services 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 these services. Therefore, we decided that the Plan does not have to pay for physician services (99214) provided on March 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a commode.  You asked the Plan to pre-approve the commode. You say that the enrollee cannot make it to the bathroom in time. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.  The Plan must follow Medicare rules. Medicare rules say that to meet coverage criteria for a commode either the beneficiary would be confined to a single room, the beneficiary is confined to one level of the home environment and there is no toilet on that level, or the beneficiary is confined to the home and there are no toilet facilities in the home. The enrollee has a bathroom in her bedroom and is able to ambulate.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the commode have not been met. Therefore, we decided that the Plan does not have to pre-approve a commode.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 28, 2021.  You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not 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 code 70450 is computed tomography, head or brain; without contrast material. We find that CPT code 70450 was billed with 70496. CPT code 70450 may be eligible for payment when billed with this code pair. However, the claim provided does not indicate the code was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on June 28, 2021.