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

 We decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the thorax (71250).  You asked the Plan to pre-approve the CT scan of the thorax. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan of the thorax. Our reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found the reviewed documentation indicates that the enrollee is a 70-year-old female with anxiety, asthma, osteoporosis, diverticulitis, gastroesophageal reflux disease, hypersensitivity lung disease, and moderate mitral regurgitation. She had two 3 mm nodules on CT scan in 2020. Repeat follow-up CT scan of the lungs was denied. According to the medical record CT scan report of September 14, 2020, of lungs and pleura shows a less than 3 mm right upper lobe pulmonary nodule. There is a right upper lobe granuloma. There is right middle lobe granuloma. There is a noncalcified left lower lobe nodule measuring 3 mm. Follow up with a CT scan on such a small spot is not recommended. The requested imaging service is not medically reasonable and 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 CT scan of the thorax have not been met. Therefore, we decided that the Plan does not have to pre-approve the computed tomography (CT) scan of the thorax (71250).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Angiography (MRA) of the head (70544) provided on September 1, 2021.

You asked the Plan to pay for the MRA. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70544 and 70551.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70544 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the Magnetic Resonance Angiography (MRA) of the head (70544) provided on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ingrezza 80mg tablets.  You asked the Plan to pre-approve Ingrezza. You say that Ingrezza is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ingrezza 80mg tablets.   Benefits for Ingrezza 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 the services (36000) provided on February 22, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 36000 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for code 36000. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (36000) provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (62320) provided on August 30, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required clinical records were not submitted.  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, the record is not signed and 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. Therefore, we decided that the Plan does not have to pay for the services (62320) provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorper 10 mg tablet.
You asked the Plan to pre-approve Prochlorper. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Specifically, the provider has indicated that this drug will not be used as full therapeutic replacement for intravenous anti-emetic drugs that would have otherwise been administered at the time of chemotherapy treatment. The criteria for coverage under Medicare Part B have not been met. Therefore, we decided that the Plan does not have to pre-approve Prochlorper 10 mg tablet.
Benefits for Prochlorper 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a leadless pacemaker.
You asked the Plan to pre-approve the requested services. You say that you do not have anything backing up your heart. The Plan denied your request. The Plan says the records do not show enrollment in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that leadless pacemakers are only covered under certain medical indications. We looked at the file and Medicare rules. The records provided do not show that you are in an approved study. 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 a leadless pacemaker.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (93042) provided on May 23, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 93042 is a column II code to column I code 93308. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (93042) provided on May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional staff and supplies over and above those usually included in a service (99072) provided on May 13, 2021.
You asked the Plan to pay for the additional staff and supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99072 has a status indicator of B.
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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.
We find that CPT code 99072 is not supported in the record. Specifically, CPT code 99072 has a status indicator of B. This means that the payment for CPT code 99072 is included in the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the additional staff and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the additional staff and supplies over and above those usually included in a service (99072) provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve push handles for a wheelchair.  You asked the Plan to pre-approve the handles. You say that this is medically necessary. The Plan denied your request. The Plan says there must be an in-home need for this request.  The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general 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 push handles for a wheelchair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided on August 30, 2021.
You asked the Plan to pay for inpatient hospital care. The Plan denied your request. The Plan says the medical records requested not sufficient.
The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection rendered on October 25, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim has not been processed by the primary insurance.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that an Explanation of Benefits from this claim has not been received from the primary insurer. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the injection rendered on October 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 6, 2021.

You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the services billed.

The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.

Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown - porcelain fused to noble metal (D2752) and core buildup, including any pins when required (D2950) for tooth 14.
You asked the Plan to pre-approve a crown and core buildup for tooth 14. You say that tooth #14 is in desperate need for restoration. The Plan denied your request. The Plan says the recurrent decay on tooth #14 does not involve 4 tooth surfaces nor does it involve any of the cusps on tooth #14 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. The Plan covers a crown and core buildup for tooth 14 when the tooth has pathologic destruction by caries or trauma and involves four or more surfaces and two or more cusps. 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 crown and core buildup for tooth 14.
Our reviewer says that the enrollee does not meet criteria for a crown and core buildup for tooth #14. Our physician reviewer found that in this instance the total volume of affected tooth structure is less than 50%, and there are no cuspal involvements and likely three surfaces to be restored. In this circumstance a conventional composite restoration would likely serve the enrollee well without cutting off the entirety of the remaining enamel of tooth to place a crown. There would be sufficient structure to function well and would not require the additional strength of a crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a crown and core buildup for tooth 14 have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown - porcelain fused to noble metal (D2752) and core buildup, including any pins when required (D2950) for tooth 14.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 19, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 19, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  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 inpatient psychiatric care from February 19, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 19, 2022, forward. Our physician reviewer found you did not require inpatient mental health treatment beyond February 19, 2022, as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis.  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 psychiatric care from February 19, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 19, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for pain management services (procedure code 62320) provided to the enrollee on September 6, 2021.  You asked the Plan to pay for the services. You say that the records are insufficient to support payment for the services. The Plan denied your request. The Plan says the services were billed correctly and should be paid for.  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 September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (62320) provided on July 26, 2021.  

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the required clinical records were not submitted.  

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, the record is not signed and 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. Therefore, we decided that the Plan does not have to pay for the services (62320) provided on July 26, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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.
Appeal type: Practitioner Services
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 18, 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 18, 2021.