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

We decided that the Plan does not have to pay for CT scans of the cervical spine (72125), the thoracic spine 
(72128), and the lumbar spine (72131) provided on November 24, 2020. 
 
You asked the Plan to pay for CT scans of the spine. You say that the requested procedures were a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for the requested 
procedures 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 pay for CT scans of the spine. Our reviewer says 
that the requested services are not medically reasonable and necessary in this case. Our physician reviewer 
found that there were no medical records associated with the injury on November 24, 2020, submitted for review. The reports of the exams each mention as the indication: "trauma, ground level fall." Such history does 
not qualify for recognized clinical indication for the scans completed. No ICD-10 code exists for ground level 
fall as same is not a symptom. Medicare rules require a recognized symptom to qualify for reimbursement and, 
in this case, there was not a mention of an area of clinical symptoms or mechanism of injury. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CT scans of the spine have not been met. Therefore, we decided that the Plan 
does not have to pay for CT scans of the cervical spine (72125), the thoracic spine (72128), and the lumbar 
spine (72131) provided on November 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-sterile gloves, per 100 (A4927).
You asked the Plan to pre-approve the gloves. You say that you want to know why your incontinent supplies were denied. You have been receiving them for years now and no changes have been made to the Plan. The Plan denied your request. The Plan says this item is not a covered item.
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 the non-sterile gloves, per 100 (A4927).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (43281) provided October 5, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 43281 is not supported in the medical record. Specifically, the operative report does not document repair of a paraesophageal hernia. The operative report documents a curvature dissection. There is not enough detail to confirm a paraesophageal hernia was repaired. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (43281) provided October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis (L1820) provided on January 21, 2021. 
 
You asked the Plan to pay for a knee orthosis. You say that the requested item is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of the requested item have not been 
met. 
 
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 a knee orthosis. Our reviewer says that the 
requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found 
that detailed documentation is not evident regarding any recent injury or a surgical procedure. There is no 
ligamentous instability and a negative posterior drawer sign is noted. There is no compelling rationale 
presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. 
 
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 knee orthosis have not been met. Therefore, we decided that the Plan does not 
have to pay for a knee orthosis (L1820) provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services represented by code 99213 provided 
on October 6, 2020. 
 
You asked the Plan to pay for code 99213. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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, code 99213 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the physician services 
represented by code 99213 provided on October 6, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT of the head and brain without dye (70450) provided on
May 3, 2021.
You asked the Plan to pay for the CT of the head and brain. You say that you would like reconsideration
because the member had multiple exams on the same date of service. The Plan denied your request. The Plan
says procedures that represent overlapping services are considered mutually exclusive.
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 the CT
of the head and brain has a bundled relationship with code 70496 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 CT of the head and brain without dye (70450)
provided on May 3, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy on tooth 30 and 31 (D3330).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 endodontic therapy on tooth 30 and 31 (D3330).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for MRI provided on April 22, 2021. 
 
You asked the Plan to waive the copayment for the MRI. You say that you were told by the agent that you 
would not have any copayments. The Plan denied your request. The Plan says you have been asked to pay the 
correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for in-network diagnostic radiology other than computed tomography (CT) scans.  
 
You have been asked to pay a $200 copayment for the MRI. The MRI falls within the "Outpatient diagnostic 
tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for the MRI provided on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services provided on February 26, 2021 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for surgical services. You say that it was the responsibility of the operating 
physician to obtain authorization to perform services in an out-of-network facility. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because this provider is out-of-
network with the Plan and authorization was not 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 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 surgical services provided on February 26, 2021 
by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room care (99285) provided January 8, 2021.
You asked the Plan to pay for the emergency room care. You say that the services were medically necessary.
The Plan denied your request. The Plan says an evaluation and management service was already paid for this
provider on this date of 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.
We find that CPT code 99285 is not supported in the medical record. Specifically, the record shows another
evaluation and management service (99283) was billed for the same date of service by the same provider.
Based on this information, we decided that Medicare rules for coverage of the emergency room care have not
been met. Therefore, we decided that the Plan does not have to pay for emergency room care (99285) provided
January 8, 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 documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with frequent physician oversight and an interdisciplinary approach to rehabilitation care. IRF admission is not medically necessary. Your rehabilitation needs can be
addressed in an alternate and less intense setting such as in a skilled nursing facility. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport
(A0429, A0425), provided on September 7, 2020.
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that the
enrollee required an IV and cardiac monitoring during transport. The Plan denied your request. The Plan says
the transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance service, basic life support,
emergency transport.
Our reviewer says that the ambulance transport was not medically reasonable and necessary. Our physician
reviewer found that upon ambulance arrival, emergency medical services reported that the enrollee was sitting
in bed alert and oriented, airway, breathing, and circulation intact. The enrollee did state that she did not feel
well. The facility staff reported loose dark colored stools that morning. The enrollee was hemodynamically
stable with stable vital signs. The enrollee's presenting symptoms did not meet prudent layperson criteria for
emergency care. The review has determined that the documentation did not support that other means of
transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated
for this enrollee. The documentation did not support that the enrollee needed the expertise, services and
lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport.
The documentation did not support that the ambulance transport on September 7, 2020 was medically
reasonable and necessary for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, basic life support, emergency transport have not been met.
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency
transport (A0429, A0425), provided on September 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lab services (81540) provided September 28, 2020.
You asked the Plan to pre-approve the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CPT 81540 is not covered. We looked at the file and Medicare rules. Medicare rules say that CPT 81540 is not likely to impact therapeutic decision-making and is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pre-approve lab services (81540) provided September 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the arterial grafting for coronary artery bypass (33548).
You asked the Plan to pre-approve the arterial grafting for coronary artery bypass. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arterial grafting for coronary artery bypass have not been met. Therefore, we decided that the Plan does not have to pre-approve the arterial grafting for coronary artery bypass (33548).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not require any skilled
nursing services and while the enrollee does require skilled therapy, they do not need it on a daily basis or in an
inpatient setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Specifically, medically necessary services can be
obtained at a lower level of care., This means SNF care is not medically necessary or reasonable. Therefore, we
decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the arthroscopy (29806).
You asked the Plan to pre-approve the arthroscopy. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 arthroscopy. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found Shoulder superior capsule reconstruction with a graft remains experimental and more research is needed to show safety and efficacy. 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 arthroscopy have not been met. Specifically, the requested service remains experimental and more research is needed to show safety and efficacy. Therefore, we decided that the Plan does not have to pre-approve the arthroscopy (29806).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Abraxane (J9264), Carboplatin (J9045), Keytruda (J9271), and Dexamethasone Sodium Phosphate (J1100).
You asked the Plan to pre-approve the Abraxane, Carboplatin, Keytruda, and Dexamethasone Sodium Phosphate. You say that the drugs are medically necessary. The Plan denied your request. The Plan says the enrollee has not met the step therapy criteria for these drugs.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Abraxane, Carboplatin, Keytruda, and Dexamethasone Sodium Phosphate. Our reviewer says that you do not meet the step therapy criteria for these drugs. Our physician reviewer found a trial of Taxol (paclitaxel) or Taxotere (docetaxel) or a documented contraindication to standard hypersensitivity premedications is required before the Plan will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 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 Abraxane, Carboplatin, Keytruda, and Dexamethasone Sodium Phosphate have not been met. Therefore, we decided that the Plan does not have to pre-approve the Abraxane (J9264), Carboplatin (J9045), Keytruda (J9271), and Dexamethasone Sodium Phosphate (J1100).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on February 3, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels for enrollees with suspected or documented cardiovascular disease.
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 test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on February 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Caris Molecular Intelligence tumor genetic testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this test is helpful for evaluation of melanoma.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested genetic testing is the CARIS MI profile. The MI profile by CARIS is not listed as a Medicare covered service on DEX Diagnostics by Palmetto GBA. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Caris Molecular Intelligence tumor genetic testing