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

 We decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing provided on July 28, 2021.  You asked the Plan to pay for the cardiovascular genetic risk assessment testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Cardiovascular risk assessment panels are only covered for certain indications.  While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing provided on July 28, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 We decided that the Plan has to pre-approve pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667), for the enrollee.  

You asked the Plan to pre-approve the DME. You say that you are treating the enrollee for chronic and severe lymphedema to both lower extremities. You state that the prior conservative treatments that have been tried include elevation, exercise, compression wraps/stockings, and enrollee education in lymphedema management. You state that despite these conservative treatments, the enrollee continues to present with Stage III lymphedema. The Plan denied your request. The Plan says that the information sent by the doctor shows that the enrollee does not have one of the qualifying skin conditions.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the DME. Our physician reviewer found the enrollee is described as having "severe" longstanding stage II lymphedema with significant stasis dermatitis which is sufficient evidence of severe lymphedema, and the enrollee had tried and failed other treatments over the years. The enrollee is a good candidate for the pump at this time and meets criteria in the LCD for Medicare coverage.  

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 DME have been met. Therefore, we decided that the Plan has to pre-approve pneumatic compressor, segmental home model without calibrated gradient pressure (CPT code E0651) and segmental pneumatic appliance for use with pneumatic compressor, full leg (CPT code E0667), for the enrollee.   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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form (CPT code 99080) provided from March 1, 2021, by out-of-network providers.

You asked the Plan to pre-approve the service. You say that you were given a list of providers by your agent, and you should not be responsible. 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. Code 99080 billed for date of service March 1, 2021, will remain upheld. Code 99080 was denied because according to the CMS Physician Fee Schedule Relative Value, code 99080 has a 'B' status which indicates a bundled code. Payment for covered services is always bundled into payment for other services not specified. If RVUs are shown, they are not used for Medicare payment. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Therefore, we decided that the Plan does not have to pre-approve the special reports such as insurance forms, more than the information conveyed in the usual medical communications or standard reporting form (CPT code 99080) provided from March 1, 2021, by out-of-network providers.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pay for magnetic resonance imaging (MRI) of the brain provided to the enrollee on August 17, 2021.  You asked the Plan to pay for the MRI. You say that this should be paid for. The Plan denied your request. The Plan says that screening testing is not a Medicare benefit.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the dictated history of the MRI for the brain was stated to be for "screening for cancer", whereas the actual indication for evaluating for metastatic disease in a patient with recently diagnosed adenocarcinoma of the lung. This diagnosis is a reasonable indication for the brain MRI, and should be covered.  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 MRI have been met. Therefore, we decided that the Plan has to pay for magnetic resonance imaging (MRI) of the brain provided to the enrollee on August 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 1, 2021, by an OON provider.  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 were rendered by an out-of-network provider without prior authorization.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 1, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve platelet-rich plasma injections.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says it is not covered for the enrollee's medical problem.  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 you are being treated for a strain of left Achilles' tendon, rupture of left Achilles' tendon. The requested platelet rich plasma injection for left ankle/foot surgery is not indicated for your condition. The requested platelet rich plasma injection for left ankle/foot surgery, in this case, is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACH criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.    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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a stair glide.  You asked the Plan to pre-approve a stair glide. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature.   While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a cone beam CT capture and interpretation (D0364).  You asked the Plan to pre-approve the dental imaging. You say that this service is necessary. The Plan denied your request. The Plan says this service is not covered by your dental 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 a cone beam CT capture and interpretation (D0364).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 1, 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 separately payable.  The Plan must follow Medicare rules. The rules say that all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid.  We looked at the file and Medicare rules. The file shows that the laboratory services were rendered for end-stage renal disease (ESRD). Payment is included in the payment to the ESRD facility. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 1, 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 a skilled nursing facility will not give the enrollee the best opportunity to regain his baseline quality of life. The Plan denied your request. The Plan says the enrollee does not require an intensive multidisciplinary approach to daily therapy.  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 physician reviewer found that the enrollee was admitted to the acute care hospital for endoscopic wedge resection of left lower lung. Her medical problems are stable.  She does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One injections.

You asked the Plan to pre-approve Synvisc-One. You say that Synvisc-One is medically necessary. The Plan denied your request. The Plan says a trial of Euflexxa and Gel One is required before alternatives can be considered.

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 Synvisc-One. Our reviewer says that Synvisc-One is not medically necessary. Our physician reviewer found the record does not show a trial of the plan preferred drugs or any reason they would be unsafe or ineffective 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One injections.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder Detect identified with code 0012M provided on August 9, 2021.  You asked the Plan to pay for the CxBladder Detect. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that CxBladder Detect is non-covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CxBladder Detect have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder Detect identified with code 0012M provided on August 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor provided on April 25, 2021.  You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 relevant medical records which support medical necessity for the supplies provided in this case. Review of the file shows that the documentation submitted did not sufficiently support the billed supply code, nor did the documentation indicate that the provider discussed the need for the billed supply code. 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 the supply allowance for therapeutic continuous glucose monitor provided on April 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on June 16, 2021.  You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  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 99233 is a column II code to column I code 43270. 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 subsequent hospital care services coded 99233 provided on June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuromonitoring services (95886, 95907, 95937) provided September 8, 2020.  You asked the Plan to pay for the neuromonitoring 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 95886, 95907, & 95937 is not supported in the medical record. Specifically, the records do not show nerve conduction studies were performed as billed. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for neuromonitoring services (95886, 95907, 95937) provided September 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 10160) provided to the enrollee on May 19, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a related procedure performed during the global surgery period, as indicated by modifier 78, is not separately reportable when the procedure did not require return to an operating room.  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 10160 is "Puncture aspiration of abscess, hematoma, bulla, or cyst."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the he medical records provided indicate this service did not meet criteria for billing with a -78 modifier, therefore 10160-78 is not eligible for reimbursement consideration.  Modifier 78 is used to report an unplanned return to the operating or procedure room, by the same physician, following an initial procedure for a related procedure during the postoperative period.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 10160) provided to the enrollee on May 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrical stimulation therapy rendered on April 14, 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 covered.    The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid for Medicare purposes.  We looked at the file and Medicare rules. Billed procedure code 97014 (electrical stimulation therapy) has a status indicator of I and is not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy rendered on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that you need these services. The Plan denied
your request. The Plan says scaling and root planing is limited to once per quadrant every 2 plan years, not to
exceed 4 unique quadrants every 2 plan years. The Plan also says that the frequency limit has been reached.

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.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of the dental services have not been met. Specifically, the file shows that the frequency limit has been
reached. The record shows that the Plan paid for scaling and root planing for the upper left and lower left
quadrants that you received on August 16, 2021, and for the upper right and lower right quadrants you received
on August 18, 2021. Therefore, we decided that the Plan does not have to pre-approve scaling and root planing
(D4341) for all 4 quadrants.