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

We decided that the Plan does not have to pre-approve CT scan, thorax, diagnostic; with contrast material(s) (CPT code 71260), for the enrollee.
You asked the Plan to pre-approve the CT scan. You say that the enrollee has stage 4 prostate cancer and the CT is needed to repeat staging following prostatectomy and nodal biopsies. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer found the record indicates that the enrollee has prostate cancer and underwent radical prostatectomy September 14, 2021. Pre-operative imaging did not reveal metastatic disease. Pathologic stage was IVa. The record indicates that the enrollee had one prostate-specific antigen (PSA) checked on September 24, 2021, that was 0.37 compared to pre-surgery when it was greater than 5. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan, thorax, diagnostic; with contrast material(s) (CPT code 71260), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay for a knee replacement.
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is no longer considered inpatient only by Medicare.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the requested total knee arthroplasty is documented to have been supported.
However, detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for inpatient hospital care associated with knee arthroplasty 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient stay for a knee replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup (D2950) and occlusal adjustment (D9951)
provided on June 24, 2021.

You asked the Plan to pay for the dental services. You say that you live on a fixed income and you believed the
Plan would pay for all your dental care. The Plan denied your request. The Plan says these services are 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 pay for the core
buildup (D2950) and occlusal adjustment (D9951) provided on June 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services billed with code 99153 for date of service April 15, 2021.
You asked the Plan to pay for code 99153. You say that the records provided support the code in dispute. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments.
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 under the OPPS when performed in the facility setting. Therefore, we decided that the Plan does not have to pay for moderate sedation services billed with code 99153 for date of service April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety protocols for the provision of evaluation, treatment or procedural services during a public health emergency (99072) provided April 8, 2021.

You asked the Plan to pay for the chiropractic services. You say that your medical records fully support and justify billing code 99072. Based on information provided, please reprocess CPT code 99072 billed on all mentioned dated of service for prompt payment. The Plan denied your request. The Plan says this service is bundled with the services provided to the enrollee and is not eligible for separate reimbursement.

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 99072 has a bundled relationship with the total episode of care 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 additional supplies and clinical staff time to perform safety protocols for the provision of evaluation, treatment or procedural services during a public health emergency (99072) provided April 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens (V2303) and anti-reflective coating, per lens (V2750) provided May 19, 2021.
You asked the Plan to provide additional payment for the trifocal lenses and anti-reflective coating. You say that you believe the denial is in error. The Plan denied your request. The Plan says the full vision allowance has already been applied to the claim.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services up to a $150 vision allowance. We looked at the file and the Plan's rules. The Plan provided documentation showing that the $150 allowance was already applied to the eyewear. Therefore, we decided that the Plan does not have to provide additional payment for the spherocylinder, trifocal, plano to plus or minus 4.00d sphere, 0.12-2.00d cylinder, per lens (V2303) and anti-reflective coating, per lens (V2750) provided May 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat facet joint injection for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says there was only 50% relief from the bilateral two-level medial branch block on 9/8/21.

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 services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the records indicate that the enrollee underwent facet joint injection in September 2021. 50% pain relief
was achieved. The record indicates that the request if for a second injection at the same levels. The elements of
the coverage criteria are not satisfied.

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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a repeat facet joint injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (96372, 97016, 97112) provided on August 18, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the clinical value and effectiveness of the procedures have not been demonstrated in the peer-reviewed literature.
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 medical services (96372, 97016, 97112) provided on August 18, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular testing provided on April 9, 2021.
You asked the Plan to pay for the testing services. You say that the critical clinical value of the testing benefits the enrollee. The Plan denied your request. The Plan says the testing is unproven.
The Plan must follow Medicare rules. Medicare rules say that the physician's request may be through clearly documented.
We looked at the file and the rules. We find that the molecular testing at issue in this appeal is not supported in the medical record. Specifically, the medical records provided do not clearly show the physician's intent that molecular testing be performed. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the molecular testing provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intracept spine procedure (a spine procedure to help with back pain) (CPT code(s): 22899 and C9752), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says the intracept procedure is considered unproven as it clinical value and effectiveness have not been demonstrated in the peer-reviewed literature. The Plan states more research is needed to show safety and efficacy of the procedure.

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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy for low back pain. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve intracept spine procedure (a spine procedure to help with back pain) (CPT code(s): 22899 and C9752), for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one additional PT visit at home beyond August 17, 2021.

You asked the Plan to pre-approve the PT visit. The Plan denied your request. The Plan says the notes provided do not support that the condition requires therapeutic activities under the supervision of a physical therapist. The Plan also says that the diagnosis does not support medical necessity.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 PT visit. Our reviewer says that home health services provided after August 16, 2021 were not medically necessary or reasonable. Our physician reviewer found by this time, you were functioning at a level commiserate with a lower level of 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 the PT visit have not been met. Therefore, we decided that the Plan does not have to pre-approve one additional PT visit at home beyond August 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram provided on December 5, 2020.

You asked the Plan to pay for the services provided. You say that the level of decision making, and treatment substantiates the billed code. The Plan denied your request. The Plan says an appropriate modifier was not 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.

We find that CPT code 93010 was billed with code 12013. We looked at the file and the rules. We find that code 93010 is separately payable when billed with an applicable modifier. The billed claim does not show that the code at issue was billed with a modifier. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on December 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neuromonitoring services (95861, 95938, G0453, 95955) provided on January 4, 2021.
You asked the Plan to pay for intraoperative neuromonitoring services. You say that this was medically necessary. The Plan denied your request. The Plan says this was billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that physicians/practitioners who furnish services to a hospital outpatient, including in a hospital outpatient department (including in a provider-based department of that hospital) or under arrangement to a hospital shall, at a minimum, report the off campus-outpatient hospital place of service (POS) code 19 or on campus-outpatient hospital POS code 22 irrespective of the setting where the patient actually receives the face-to-face encounter.
We looked at the file and Medicare rules. The records show that the services at issue were provided to an outpatient but were billed with an inpatient place of service code. Based on this information, we decided that Medicare rules for coverage of intraoperative neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative neuromonitoring services (95861, 95938, G0453, 95955) provided on January 4, 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 an IRF is more ideal than a lower level facility. 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 respiratory failure and coronavirus pneumonia. Her medical problems are stable. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on March 19, 2021, by an
OON provider.
You asked the Plan to pay for an eye refraction. You say that you temporarily moved to your daughter's
residence in a different town and would like to be reimbursed for the service. The Plan denied your request.
The Plan says services were provided 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 six (6) network
providers available who could have provided the items/services at issue in this appeal. The Plan did not preapprove
the item/service at issue. The records provided for review do not show that the services at issue were
urgent or emergent. 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 an eye refraction (92015) provided on March 19,
2021, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve (MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141) and MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the enrollee.
You asked the Plan to pre-approve the MRIs. You say that the enrollee has severe pain and they had lumbar fusion. The Plan denied your request. The Plan says the records do not show failure of recent (within 3 months) 6-week trial of provider-directed treatment.
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 pre-approve the MRIs. Our physician reviewer found the records provided did not show that the enrollee was to undergo another surgical procedure or have evidence of a red flag diagnosis from examination findings to justify MRI at this time for either the cervical or lumbar spine areas. There were no recent structured efforts for treatment such as physical therapy (PT) or pain management changes to show a failure of conservative treatments. Therefore, the cervical and lumbar spine MRIs will be considered not medically necessary based on the provided documentation. 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 MRIs have not been met. Therefore, we decided that the Plan does not have to pre-approve (MRI, spinal canal and contents, cervical; without contrast material (CPT code 72141) and MRI, spinal canal and contents, lumbar; without contrast material (CPT code 72148), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 24, 2020, by an out-of-
network provider.

You asked the Plan to pay for the office visit (99213). You say that the Plan should pay this claim. The Plan
denied your request. The Plan says prior authorization was not obtained as required.

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 service at issue in this appeal. The Plan did not pre-approve the service
at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that
the Plan does not have to pay for the office visit provided on December 24, 2020, by an out-of-network
provider.