Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for endoscopy procedures (43264, 43261) provided on May 17, 2021.
You asked the Plan to pay for endoscopy procedures. You say that these services are supported in the records. The Plan denied your request. The Plan says that these codes are bundled into 43275.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules also say if Field 21 of the Medicare Fee Schedule Database (MFSDB) contains an indicator of "3," and multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. Pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has stated that the MFSDB indicator, base endoscopy, and special rules for endoscopies mean that codes 43264 and 43261 are bundled into 43275. However, the referenced rules do not indicate that these codes are bundled. The referenced rules indicate that the Plan must pay the full value of the highest valued endoscopy, plus the difference between the next highest and the base endoscopy. The submitted documentation does not indicate that the Plan has done so. Therefore, we decided that the Plan has to pay for endoscopy procedures (43264, 43261) provided on May 17, 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network
(OON) provider.
You asked the Plan to pre-approve an office visit. You say that this care is medically reasonable and necessary.
The Plan denied your request. The Plan says they have in-network providers available for the enrollee.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy
assistant on January 13, 2021.
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay noncontracted
providers at the preferred provider rate if services are not available from preferred providers in the
service area. You say that the in-network benefits should be honored, and the claim processed for payment. The
Plan denied your request. The Plan says the records do not support the code billed.
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA)
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they
do not meet the qualifications of a therapist.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services
provided by a physical therapy assistant on January 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthetic injection services provided on March 4, 2021.
You asked the Plan to pay for the services provided. You say that you have followed the correct billing guidelines. The Plan denied your request. The Plan says the claim is not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.
In this case, the CPT Code Manual definition of code 64415 is injection(s), anesthetic agent(s) and/or steroid;
brachial plexus. We find that CPT code 64415 is not supported. Specifically, the service was not billed to
indicate which side the service was performed on. Based on this information, we decided that Medicare rules
for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to
pay for the anesthetic injection services provided on March 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 power scooter. Our reviewer says that the item is not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. The power scooter is being requested for "outdoor needs."
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 power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the overdenture - complete mandibular (D5865) and precision attachments (D6950) provided August 18, 2021.
You asked the Plan to pre-approve the complete lower overdenture and precision attachments. You say that you would like the services covered. The Plan denied your request. The Plan says these services are not covered under your benefits.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the overdenture - complete mandibular (D5865) and precision attachments (D6950) provided August 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency transport services (A0429) provided on April 27, 2021.
You asked the Plan to pay for the emergency transport services. You say that you would like reconsideration because this claim was billed with the appropriate modifier. The Plan denied your request. The Plan says this claim was not billed according to Medicare billing guidelines.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A0429 is not supported in the record. Specifically,in instances where the beneficiary is pronounced dead after the ambulance is called, providers must report CPT code A0428 with the QL modifier. This claim was not billed with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the emergency transport services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency transport services (A0429) provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0651, E0667) provided February 9, 2021.
You asked the Plan to pay for the pneumatic compression devices. You say that the items were medically necessary. The Plan denied your request. The Plan says the records provider were not sufficient to support that coverage criteria has been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain sufficient relevant medical records which support medical necessity for the supplies provided in this case. The records provided are insufficient to meet the requirements of Local Coverage Article (LCA) A52488 - Pneumatic Compression Devices. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0651, E0667) provided February 9, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities provided on March 15, 2021.
You asked the Plan to pay for therapeutic activities. The Plan denied your request. The Plan says that the Plan has insufficient documentation to corroborate the services so the Plan cannot confirm Medicare coverage has been met.
The Plan must follow Medicare rules. Medicare rules say that when therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other incident to requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on March 15, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Cologuard testing provided on April 6, 2021.
You asked the Plan to pay for Cologuard testing. You say that this is a covered service. The Plan denied your
request. The Plan says medical records have not been submitted.
The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered once every three
years for Medicare beneficiaries that meet specific criteria. The rules also say that the provider, supplier, or
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine
whether payment is due and the amount of payment.
We looked at the file and Medicare rules. No medical records have been submitted to show whether the criteria
for coverage have been met. Based on this information, we decided that Medicare rules for coverage of
Cologuard testing have not been met. Therefore, we decided that the Plan does not have to pay for Cologuard
testing provided on April 6, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder Detect test provided on May 4, 2021.
You asked the Plan to pay for the Cxbladder Detect test. You say that the Cxbladder Detect test was medically necessary. The Plan denied your request. The Plan says the Cxbladder Detect test is not covered by Medicare.
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 Cxbladder Detect test. Our reviewer says that the Cxbladder Detect test is not considered medically reasonable and necessary in this case.
Our physician reviewer found Cxbladder Detect test is considered experimental/investigational as a screening test for urothelial cancer. Cystoscopy, ureteroscopy, possible biopsy and upper tract imaging will still be necessary regardless of the results of Cxbladder Detect testing. Urinary biomarker tests such as CxBladder give significant false-negative results in patients with urothelial cancer and are subject to false-positive results in others. Accuracy is poor for low-stage and low-grade tumors. To date, there are multiple urine markers that have improved sensitivity over cytology but there is lack of validation of clinical utility. Some of the recently developed markers aim to change the paradigm of urothelial diagnosis and follow-up by replacing or reducing the need of invasive investigations. Further prospective validations are needed to confirm these findings. 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 Cxbladder Detect test have not been met. Therefore, we decided that the Plan does not have to pay for the Cxbladder Detect test provided on May 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this surgery is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The Food and Drug Administration states that the Superion Interspinous Spacer is indicated to treat skeletally mature patients suffering from pain, numbness, and/or cramping in the legs (neurogenic intermittent claudication) secondary to a diagnosis of moderate lumbar spinal stenosis, with or without Grade 1 spondylolisthesis, confirmed by X-ray, magnetic resonance imaging and/or computed tomography evidence of thickened ligamentum flavum, narrowed lateral recess, and/or central canal narrowing. In this case, the documentation indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication.
The record indicates that imaging does not demonstrate moderate foraminal or spinal stenosis at the level requested for treatment. 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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
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 you need IRF care. The Plan denied your request.
The Plan says the rules for IRF care have not been met.
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 that you were admitted for encephalopathy, hyponatremia, hypomagnesemia and
has been discharged home where you are living with your daughter. There is progressive weakness despite
home health physical therapy. 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 you have a need for physical and/or
occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In
conclusion, 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission and a left atrial appendage closure (LAAC) device.
You asked the Plan to pre-approve inpatient admission and LAAC device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with specific 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 inpatient admission and LAAC device. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record does not document the occurrence of a shared decision-making interaction or that the enrollee is not a candidate for continued oral anticoagulation. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission and LAAC device have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission and a left atrial appendage closure (LAAC) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a third level of facet joint injections (64495) provided on
June 9, 2021.
You asked the Plan to pay for a third level of facet joint injections. You say that this was medically necessary.
The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that one to two levels of facet joint interventions,
either unilateral or bilateral, are allowed per session per spine region. The need for a three or four-level
procedure bilaterally may be considered under unique circumstances and with sufficient documentation of
medical necessity on appeal.
We looked at the file and Medicare rules. The submitted medical records do not document unique
circumstances requiring a three level procedure. Based on this information, we decided that Medicare rules for
coverage of a third level of facet joint injections have not been met. Therefore, we decided that the Plan does
not have to pay for a third level of facet joint injections (64495) provided on June 9, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided July 22, 2021.
You asked the Plan to pay for the root canal. You say that you feel the provider gave you incorrect information about the cost of the services. The Plan denied your request. The Plan says this service is not covered under your benefits.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy, premolar tooth (excluding final restoration) (D3320) provided July 22, 2021.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 inpatient rehabilitation facility (IRF) admission and services.