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

We decided that the Plan does not have to pay for the nail debridement you received on May 13, 2021.
You asked the Plan to pay for the foot care. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. The records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the foot care have not been met. Therefore, we decided that the Plan does not have to pay for the nail debridement you received on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care (CPT code(s): 11043, 11042, 11044, 11045)
provided to the enrollee on May 12, 2021, by an out-of-network provider.
You asked the Plan to pay for the wound care. You say that review and process payment for the medically
necessary services rendered to the enrollee urgently in need of care. The Plan denied your request. The Plan
says this provider is out-of-network, the services were not referred by a network provider, and the services
were not urgent or emergent, nor were they approved in advance.
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 wound care (CPT code(s): 11043, 11042,
11044, 11045) provided to the enrollee on May 12, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of subcutaneous tissue (11042), debridement of bone (11044), debridement of muscle and/or fascia (11043), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on April 26, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the debridement of subcutaneous tissue (11042), debridement of bone (11044), debridement of muscle and/or fascia (11043), and the chemical cauterization of granulation tissue (17250) rendered by the out-of-network (OON) provider on April 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on March 30, 2021.
You asked the Plan to pay for out of network services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 out of network physician services provided to the enrollee on March 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) for treatment of
a lung tumor.
You asked the Plan to pre-approve the PBRT. You say that the enrollee has had prior radiation exposure and
would benefit from PBRT for the ability to reduce dose to healthy tissues. The Plan denied your request. The
Plan says there is insufficient evidence to support that photon-based treatment would exceed dose constraints.
The Plan follows Medicare rules. Medicare rules say that PBRT for lung cancer would generally only be
covered in clinical trials or registries. There are also specific documentation requirements to support the need
of PBRT over other radiation treatments 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 the PBRT. Our reviewer says that the
documentation does not support that criteria for this treatment are met. Our physician reviewer found no
specific dosimetric rationale is provided in this case, with the appeal note written in generic terms about how
proton therapy can be used to reduce the dose-volume exposure of normal tissues. A plan comparison is
provided for the planned treatment as well as a composite with the prior treatment; the non-proton-based plans
does not show unacceptable normal tissue exposure. The 8/4/21 peer review outlined in great detail how both
treatment plans meet accepted dose constraints and the radiation oncologist for this patient did not provide 
quantifiable rationale for why proton therapy would be needed. SBRT technique - even if delivered over 15
fractions - would result in low lung exposures, particularly with a lung lesion abutting the chest wall. The high
dose regions of the prior treatment do not overlap with the current treatment and it is not evident that proton
therapy would result in a meaningful reduction in this dose overlap. In summary, there is no evidence that
proton therapy is needed over other accepted treatments. There is no plausible reason that proton therapy would
be more beneficial than standard therapy for this particular patient.
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 PBRT have not been met. Therefore, we decided that the Plan does not have
to pre-approve proton beam radiation therapy (PBRT) for treatment of a lung tumor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D0367).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the service is not covered under the enrollee's 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 dental services (D0367).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0483) provided on October 21, 2020.
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your
request. The Plan says this was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan
does not have to pay for drug testing (80307, G0483) provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on March 6, 2021.
You asked the Plan to pay for the cardiovascular risk assessment panel. 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 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. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36139, L36129, L36362, and L36523 to support their denial. However, LCD L36139, L36129, L36362, and L36523 are not valid for the provider's billing state of Pennsylvania. Therefore, we are unable to use LCD L36139, L36129, L36362, and L36523 to substantiate our decision. 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 risk assessment panel provided on March 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete maxillary and mandibular dentures (D5110, D5120) received on May 24, 2021.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says this exceeds the maximum amount allowed per period.
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 dentures once every five years. Dentures were received less than five years before the May 24, 2021 date of service on February 7, 2020. Based on this information, we decided that the Plan's rules for coverage of the services have not been met.
Therefore, we decided that the Plan does not have to pay for complete maxillary and mandibular dentures (D5110, D5120) received on May 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested viscosupplement device.
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 Euflexxa. Our reviewer says that Euflexxa is not approved as step criteria have not been met. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires that these be trialed first. Our reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered or that the Plan's required drugs 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
You asked the Plan to pre-approve the portable home ventilator. You say that the ventilator is medically necessary. The Plan denied your request. The Plan says the enrollee's needs are met by a BiPAP device.
The Plan follows Medicare rules. Medicare rules say that the decision to use a ventilator or a bi-level positive airway pressure device is made based upon the specifics of each person's medical condition. 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 portable home ventilator. Our reviewer says that the requested device is not medically necessary. Our physician reviewer found a home ventilator is not medically necessary for this patient. She has COPD and recurrent admissions with respiratory failure. She improves with BiPAP in the hospital. There is no documentation of BiPAP failure at home. 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 portable home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable home ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like more physical therapy. The Plan denied your request. The Plan says that your needs can be safely met at a lower level of care.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for right knee replacement.
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a Tempus Homologous Recombination Deficiency (HRD) panel (81479) provided on December 11, 2020.
You asked the Plan to pay for a Tempus HRD panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported.
The Plan must follow Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when the diagnostic laboratory test has Food & Drug Administration (FDA) approval or clearance.
We looked at the file and Medicare rules. The records show that the testing at issue does not have FDA approval or clearance. Based on this information, we decided that Medicare rules for coverage of a Tempus HRD panel have not been met. Therefore, we decided that the Plan does not have to pay for a Tempus Homologous Recombination Deficiency (HRD) panel (81479) provided on December 11, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 11, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the enrollee is deceased, but you would like this bill to be paid. The Plan denied your request. The Plan says the ambulance benefit is a transport benefit. The Plan also says that if no transport of a Medicare beneficiary occurs, then there is no Medicare covered service.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on March 11, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on March 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided November 10, 2020.
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says services for outpatient mental health care are not covered when performed by a licensed professional counselor.
The Plan must follow Medicare rules. Medicare rules say that mental health services are only covered when provided by certain types of health professionals. 
We looked at the file and Medicare rules. In this case, the mental health services provided were performed by a licensed professional counselor which is not an eligible provider type according to Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychiatric diagnostic evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided November 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel (CPT code 0242U) provided to the enrollee on May 12, 2021.
You asked the Plan to pay for the services. You say that the enrollee meets the ordering criteria for the service rendered. The Plan denied your request. The Plan says two or more diagnosis codes associated to CPT code 0242U are mismatched.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. According to the ICD-10-CM Official Guidelines for Coding and Reporting, some ICD-10-CMcodes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. It is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available; therefore, the reported service has been denied. 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 targeted genomic sequence analysis panel (CPT code 0242U) provided to the enrollee on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CT scan of the head or brain (CPT code 70450-26) provided to the enrollee on April 20, 2021.
You asked the Plan to pay for the CT scan. You say that the claim was billed with the correct place of service. The Plan denied your request. The Plan says the incorrect place of service was billed for this service.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Review of the file shows the claim
was billed with an inappropriate place of service 22 (outpatient). According to claims history, the enrollee was inpatient during this date of service per the claim, for date of service April 17, 2021, through April 30, 2021. Therefore, we decided that the Plan does not have to pay for CT scan of the head or brain (CPT code 70450-26) provided to the enrollee on April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 11, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 pay for the lab services provided on January 11, 2021.