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

 We decided that the Plan does not have to pay for the physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session (CPT code 99183) provided to the enrollee on March 5, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the physician contacted the plan on March 1, 2021, for prior authorization of hyperbaric oxygen (HBO) therapy. The Plan states authorization was granted for HBO therapy from March 2, 2021, through May 26, 2021, but only one (1) unit was approved. The Plan states since HBO therapy requires a series of sessions, it appears the 1-unit authorization was entry error and authorization was granted to the out-of-network physician for provider GAP deficiency. The Plan states the physician submitted the same claim for the March 5, 2021, HBO therapy three (3) separate times under claims. The Plan states one claim denied as definite duplicate and the other two (2) claims denied for UM1. The Plan states these claims are identical with the same date of service (DOS), same CPT code, same diagnosis, same place of service, same provider. Furthermore, the clinical documentation supports a single treatment with HBO on the date of service; therefore, overturn the denial of CPT 99183 under claim #7001 for meeting coverage criteria under Medicare National Coverage Determination Hyperbaric Oxygen Therapy 20.29. The Plan states to uphold denial of CPT 99183 under claim #7300 for definite duplicate claim per Medicare Claims Processing Manual, 100-04, Chapter 1- General Billing Requirements, 120- Detection of Duplicate Claims.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  This is a definite duplicate claim and not able to be paid. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session (CPT code 99183) provided to the enrollee on March 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ameluz (J7345).  You asked the Plan to pre-approve Ameluz. You say that Ameluz is the most medically appropriate treatment for the enrollee. The Plan denied your request. The Plan says there is no medical record documentation of therapeutic failure on, intolerance to, or contraindication to topical Fluorouracil.  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 Ameluz. Our reviewer says that Ameluz (J7345) is not medically reasonable and necessary for the enrollee. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the Plan's preferred step one alternative, topical Fluorouracil. Our reviewer found that the record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the Plan's preferred step one alternative. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and 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 Ameluz have not been met. Therefore, we decided that the Plan does not have to pre-approve Ameluz (J7345).
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. The Plan denied your request. The Plan says the enrollee's ongoing needs can be provided 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 physician reviewer found that the enrollee was admitted to the acute hospital for thoracolumbar surgery. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal cord injection (62320) provided on August 30,
2021.

You asked the Plan to pay for the spinal cord injection (62320). You say that the procedure billed is for
subarachnoid injection therefore the policy of interlaminar epidural injections is not applicable. You say that
subarachnoid opioids are very effective for decreasing pain and the service should be paid. The Plan denied
your request. The Plan says the provider has not submitted any clinical records to support the medical necessity
of the service.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment. The rules also say 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 spinal cord injection (62320) have not been met. Specifically, medical records were not
submitted to determine if Medicare coverage criteria have been met. Therefore, we decided that the Plan does
not have to pay for the spinal cord injection (62320) provided on August 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy rendered on July 26, 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 that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.  We looked at the file and Medicare and the Plan's rules. The file shows that home infusion therapy services were rendered. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered on July 26, 2021.   Benefits for these services 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine.  You asked the Plan to pre-approve the MRI. You say that the requested MRI is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee meets the conditions for coverage of an MRI.  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 MRI. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no recent trial and failure of 6 weeks of physical therapy for low back pain. More conservative measures are 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the spine.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit.  You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the treatment is not reasonable or necessary at this time.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Retacrit. Our physician reviewer found that the requested use of Retacrit is not FDA approved for the enrollee's diagnosis. The enrollee has iron deficiency anemia that needs to be corrected and no evidence of a rationale for Retacrit use. 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 requested 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without dye (72148).  You asked the Plan to pre-approve the MRI. You say that this MRI is medically necessary for this enrollee, who is in a great deal of pain. The Plan denied your request. The Plan says the requested MRI is not medically necessary.  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 MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found that the enrollee had a previous MRI on May 11, 2021, which revealed multilevel changes. The enrollee has facet arthropathy and degenerative listhesis. Review of the records show no red flags to mandate repeat imaging as there is no documented change in her symptoms since the previous MRI. Thus, the medical necessity of a repeat MRI at this point has not been established. In addition, no physical therapy notes are present in the submitted records.  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 not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine without dye (72148).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve use of pegfilgrastim (Udenyca).

You asked the Plan to pre-approve pegfilgrastim. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because there is no medical need for pegfilgrastim.

The Plan follows Medicare rules. Medicare rules state that pegfilgrastim may be covered for Food & Drug Administratin (FDA) approved label indications with certain off-label exceptions. 

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 pegfilgrastim. Our reviewer says that the enrollee meets the Medicare criteria for pegfilgrastim. Our physician reviewer found the combination of cisplatin and gemcitabine carries and intermediate risk of neutropenic fever. However, prior radiation and the enrollee's age increase this risk to greater than 20%, especially given the additional risk of COVID-19. Pegfilgrastim is used to decrease the risk of neutropenic fever in high-risk patients. This drug is medically reasonable and 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 pegfilgrastim have been met. Therefore, we decided that the Plan has to pre-approve use of pegfilgrastim (Udenyca).

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 70544-26 billed for date of service September 23, 2021.  You asked the Plan to pay for procedure code 70544-26. You say that the patient had multiple exams on this date of service. The Plan denied your request. The Plan says you did not bill this procedure code with an appropriate payment modifier that would unbundle it and permit 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, we have confirmed that code 70544-26 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 procedure code 70544-26 billed for date of service September 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chest x-ray (CPT code 71045) provided to the enrollee on May 17, 2021.  You asked the Plan to pay for the chest x-ray. 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 71045 is a column II code to column I code 71046. 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 chest x-ray (CPT code 71045) provided to the enrollee on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radiofrequency ablation of the sacroiliac (SI) joint nerves and related outpatient hospital services provided on September 15, 2021.  You asked the Plan to pay for the RFA of the SI joint and related services. You say that this should be covered per the medical records. The Plan denied your request. The Plan says this is an experimental procedure. As this was correctly denied, the other codes were denied as they were all incidental to the denied procedure.  The Plan must follow Medicare rules. Medicare rules say that RFA of the SI joint nerves is not considered reasonable and necessary.  Since the procedure was correctly denied, the related hospital services are also noncovered. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation of the sacroiliac (SI) joint nerves and related outpatient hospital services provided on September 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle/intracatheter services rendered on May 4, 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 36140 (introduction of needle or intracatheter, upper or lower extremity artery) and 36217 (selective catheter placement). Code 36140 is a column II code with a modifier indicator of 1 when billed with column I code 36217. Code 36140 was not billed with an appropriate modifier to allow for separate payment. The records do not support the -59 modifier as a separate and distinct procedure. Therefore, we decided that the Plan does not have to pay for the needle/intracatheter services rendered on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the evaluation and management services provided on April 13, 2021.  You asked the Plan to pay for the services provided. You say that this should be processed separately to the primary procedure. The Plan denied your request. The Plan says the service is not allowed separately.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. Postoperative evaluation and management services related to the surgery/procedure are not separately reportable by the anesthesia practitioner. 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 evaluation and management services provided on April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services rendered on June 13, 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 payment for codes with a status indicator of B is always bundled into payment for other services not specified.  We looked at the file and Medicare rules. Billed procedure code 99053 (service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the medical services rendered on June 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient office visit (99202) radiologic examination, spine, lumbosacral (72100) radiologic examination, spine, cervical (72040) provided June 28, 2021.  You asked the Plan to pay for the chiropractic services. You say that you do not understand why this was denied when this chiropractor is with the Plan. The Plan denied your request. The Plan says these services are not covered when rendered by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99202) radiologic examination, spine, lumbosacral (72100) radiologic examination, spine, cervical (72040) provided June 28, 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. The Plan denied your request. The Plan says the enrollee does not need a team of providers.

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 encephalopathy and weakness. 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. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.

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 pre-approve Next Generation Sequencing genetic testing.  You asked the Plan to pre-approve Next Generation Sequencing genetic testing. You say that the records provided support the need for the requested testing. The Plan denied your request. The Plan says the guidelines for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing genetic testing is covered for certain clinical indications.   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 Next Generation Sequencing genetic testing. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a cerebral inflammatory lesion of unknown etiology. The enrollee was found to have a right-sided cerebellar mass which was resected in November 2021. A biopsy of the brain mass revealed nonspecific lymphohistiocytic infiltrate. The differential diagnosis was autoimmune versus infectious. Many infectious agents were evaluated on neuropathologic evaluation and were negative. Initial screening serum autoimmune testing was also negative. There is no evidence of brain neoplasm.  The enrollee does not have a cancer diagnosis. The role of Next Generation Sequencing genetic testing has not been established in this particular clinical setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Next Generation Sequencing genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Next Generation Sequencing genetic testing.