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

 We decided that the Plan does not have to pay for the anesthesia services coded as 01830 provided on August 6, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in accordance with Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that the correct POS code is that of the appropriate inpatient POS code or that of the appropriate outpatient hospital POS code.  We looked at the file and Medicare rules. In this case, the documentation affirms that the enrollee was in an inpatient hospital facility during the dates of service in question. However, the POS code billed for the anesthesia services coded as 01830 was 22 representing an outpatient hospital. Since the record indicates the enrollee was in an inpatient facility, the claim has not been billed correctly in this case. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 01830 provided on August 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the MRA, head; without contrast material(s) (CPT code 70544) provided to the enrollee on September 24, 2021.  You asked the Plan to pay for the MRA. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as 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, 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 MRA, head; without contrast material(s) (CPT code 70544) provided to the enrollee on September 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021.  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 services are not billed correctly.  The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.   We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) provided on August 17, 2021.  You asked the Plan to pay for the fluoroscopic guidance for needle placement (77002). You say that the patient's medical records validate medical necessity, and the claim should be processed for payment. The Plan denied your request. The Plan says this HCPCS code is assigned a payment indicator N1 which does not allow for separate payment.  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 77002 is fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure).  We find that CPT code 77002 is not supported in the medical record. Specifically, CPT code 77002 has a payment indicator of N1. This means that CPT code 77002 is considered a packaged service and not separately payable. Based on this information, we decided that Medicare rules for coverage of the fluoroscopic guidance for needle placement (77002) have not been met. Therefore, we decided that the Plan does not have to pay for the fluoroscopic guidance for needle placement (77002) provided on August 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279).  You asked the Plan to pre-approve arthrodesis, sacroiliac joint. You say that the requested arthrodesis, sacroiliac joint is medically necessary. The Plan denied your request. The Plan says the requested arthrodesis, sacroiliac joint does not meet criteria.  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 arthrodesis, sacroiliac joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found minimally invasive SI joint fusion is experimental for degenerative low back pain. Long term outcomes and complications are not well-defined. More research is needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of arthrodesis, sacroiliac joint have not been met. Therefore, we decided that the Plan does not have to pre-approve arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance, includes obtaining bone graft when performed, and placement of transfixing device (27279).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye exam established patient (92012), Ophthalmic Scanning Laser (92134), eye injection (67028), and Avastin (J7999) provided out-of-area on July 27, 2021.  You asked the Plan to pay for the eye exam, Ophthalmic Scanning Laser, eye injection and Avastin. You say that you would like reconsideration because these services are medically necessary and urgent in an eight-week interval. The Plan denied your request. The Plan says these services were not urgent, emergent, or authorized in advance by the Plan.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the eye exam, Ophthalmic Scanning Laser, eye injection and Avastin have not been met. Specifically, the documentation submitted does not include any clinical information to validate the medical necessity and urgency of these services. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the eye exam established patient (92012), Ophthalmic Scanning Laser (92134), eye injection (67028), and Avastin (J7999) provided out-of-area on July 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve kyphoplasty (22515) for the enrollee.  You asked the Plan to pre-approve these services. You say that the enrollee is in severe pain and has an acute fracture. The Plan denied your request. The Plan says that Medicare coverage guidelines are not met.  The Plan must follow Medicare rules. Medicare rules say that kyphoplasty can be covered if the Medicare criteria have been met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no documentation that the fracture is less than 12 weeks old. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty (22515) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded as 00914 provided on August 19, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the CPT code billed is not appropriate for the services that were rendered.  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 00914 is anesthesia for transurethral procedures (including urethrocystoscopy); transurethral resection of prostate.  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 the anesthesia services. Our reviewer says that the documentation does not support payment for the services as billed. Our reviewer found the primary procedure reported does not support anesthesia services for transurethral resection of prostate. A more appropriate code to report for to support the primary procedure would be CPT 00910 Anesthesia for transurethral procedures, not otherwise specified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded as 00914 provided on August 19, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from June 7, 2021, through June 25, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient admission is not medically necessary. Observation level of care is appropriate.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 7, 2021, through June 25, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Cxbladder Detect (CPT code 0012M) provided to the enrollee on July 15, 2021.  You asked the Plan to pay for the Cxbladder Detect. You say that the evidence supporting the use of Cxbladder Detect as a medically necessary diagnostic service is well established. The Plan denied your request. The Plan says these services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and is done for screening purposes.  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.  Diagnosis: R31.29/Other microscopic hematuria. These services are not authorized because molecular genetic screening testing is not a Medicare benefit for the diagnoses as listed on the claim and is done for screening purposes. The test at issue in this appeal, the Cxbladder Detect, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Cxbladder Detect (CPT code 0012M) provided to the enrollee on July 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code S9502 billed for dates of service June 30, 2021, to July 6, 2021.  You asked the Plan to pay for procedure code S9502. You say that you have provided medical records to support payment. The Plan denied your request. The Plan says this is not a payable code.  The Plan must follow Medicare rules. Medicare rules say codes that have a status indicator of "I" are not valid for Medicare purposes.  You billed with code S9502, which has a status indicator of "I". Therefore, we decided that the Plan does not have to pay for procedure code S9502 billed for dates of service June 30, 2021, to July 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Revlimid for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  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 Revlimid for the enrollee.   Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a CardioMEMS device.  You asked the Plan to pre-approve the requested services. You say that the goal is to reduce heart failure hospitalizations. The Plan denied your request. The Plan says there is a lack of published scientific literature to support its use.  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 requested services. Our physician reviewer found that the enrollee has recurrent congestive heart failure. This request is for a CardioMEMS pulmonary pressure sensor implantation to help improve fluid management and symptoms. The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in those who the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. There remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this enrollee's clinical management. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four prefabricated abutments (D6056 x4).  You asked the Plan to pre-approve the prefabricated abutments. You say that you would like to appeal these services. The Plan denied your request. The Plan says this service is not covered under your benefit plan.  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 four prefabricated abutments (D6056 x4).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synthroid tablet.

You asked the Plan to pre-approve Synthroid. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Synthroid tablet.

Benefits for Synthroid 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that the records provided support the need for the requested compression stockings. The Plan denied your request. The Plan says the requested compression garments are not medically necessary.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for brain imaging, positron emission tomography (PET) (78608).  You asked the Plan to pay for the PET scan. You say that you are trying to appeal the denial for the Pet Scan of the brain because the enrollee really needs this scan. The Plan denied your request. The Plan says the requested service is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that PET 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 the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the office visit note provided for review did not raise suspicion of Alzheimer's dementia and/or frontotemporal dementia. There likewise was no indication that the member met diagnostic criteria for both forms of dementia. Rather, the provider also speculated that some of the member's medical problems could be related to a prior stroke with resulting encephalomalacia. As the member is not suspected o having both Alzheimer's dementia and frontotemporal dementia, the base Medicare requirement for coverage would not have been met. This therefore would not meet criteria for coverage and is not medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for brain imaging, positron emission tomography (PET) (78608).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).  You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says Keytruda is not approved for the enrollee's condition.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our physician reviewer found that the enrollee has non-small cell lung cancer. The requested use of Keytruda is not FDA approved for the enrollee's diagnosis. FDA approval is for the first-line treatment (in combination with pemetrexed and platinum chemotherapy) of metastatic non-squamous NSCLC in those with no EGFR or ALK genomic tumor aberrations. There is no evidence of this testing. The use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).