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

 We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility (99053) provided on April 6, 2021.  You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99053 has a status indicator of B.  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 99053 is not supported in the record. Specifically, CPT code 99053 has a status indicator of B. This means that the payment for CPT code 99053 is always bundled into the payment for another procedure or service. Based on this information, we decided that Medicare rules for coverage of the services provided between 10:00 PM and 8:00 AM at 24-hour facility have not been met. Therefore, we decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility (99053) provided on April 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the therapeutic parenteral drug (D9610), provided on September 7, 2021.  You asked the Plan to pre-approve the therapeutic parenteral drug. You say that the service should be covered. The Plan denied your request. The Plan says this is not a covered service.  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 the therapeutic parenteral drug (D9610), provided on September 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to pay for the outpatient mental health services (90837) provided on August 25, 2021.  You asked the Plan to pay for the outpatient mental health services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says that there is no indication that this provider communicated with the member's treating physician.  The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have been met. Specifically, the claim indicates that these services were rendered by a CSW. There are no Medicare criteria indicating that a CSW must communicate with the member's treating physician. The Plan has not forwarded any additional evidence to substantiate why these services are not payable. Therefore, we decided that the Plan has to pay for the outpatient mental health services (90837) provided on August 25, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0483, 80307) provided on February 8, 2021.  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 not billed correctly.  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 11 for an office setting, but the record shows that the sample was taken in a psychiatric facility. 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 (G0483, 80307) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided the Plan does not have to pay for medical services billed under codes 88341 and 88342.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 88360 and 88342. This PTP edit has a modifier indicator of 1, modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.   Procedure code 88341 is an add-on code to procedure code 88342. Since the primary code has not been approved for payment, the add-on code is not eligible for payment.   The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when necessary, the appropriate modifiers. In this case, we have confirmed 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 medical services provided to the enrollee on August 10, 2021 and billed under codes 88341 and 88342.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve positron emission tomography (PET) services with computed tomography (CT) skull to mid-thigh.  You asked the Plan to pre-approve the PET/CT scan. You say that the records provided support the need for the requested PET scan. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of a PET scan.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET/CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a repeat PET scan of the chest is not medically necessary. The enrollee has a LUL cavitary, spiculated nodule that is suspicious for malignancy.  It was first identified on a chest CT in January 2020 and was found to be hypermetabolic on PET scan on January 16, 2020.  There is no reason to repeat the PET scan, since the nodule has already been established to be hypermetabolic.  It would be reasonable to follow the nodule by chest CT, per Fleischner criteria.  Repeating the PET does not add anything to this, unless there is suspicion for metastases, or surgical resection is planned.  The clinic note does not indicate this is the case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the PET/CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) services with computed tomography (CT) skull to mid-thigh.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the outpatient clinic visit (G0463) provided on October 3, 2017.   You asked the Plan to pay for the outpatient clinic visit (G0463). You say that the claim has not been paid in full or under the terms of the contract for the services provided to this patient. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.  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 G0463 is a column II code to column I code 96374. 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 outpatient clinic visit (G0463) provided on October 3, 2017.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Posaconazole 100 mg tablet.  You asked the Plan to pre-approve Posaconazole. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Posaconazole 100 mg tablet.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve revision of the upper eyelid with repair of brow defect.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that eyelid procedures are covered when specific criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has dermatochalasis of the right upper eyelid. It is documented that the enrollee had "no improvement in loss of vision due to droopy lid." There is insufficient evidence of interference with the enrollee's visual field, near or far visual impairment, or difficulty reading due to dermatochalasis. The margin to reflex distance (MRD1) is not 2.0 millimeters or less. The photographs do not suggest that the enrollee is looking through the eyelashes or seeing the upper eyelid skin as commonly seen with ptosis. The procedures are not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve revision of the upper eyelid with repair of brow defect.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) (G6015).  You asked the Plan to pre-approve IMRT. You say that the requested intensity modulated radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested intensity modulated radiation therapy does not meet criteria.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IMRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee received radiation therapy in 2006 and 2018. There is evidence of continued progression of metastatic disease in the pelvis. Palliative radiation treatment to the left iliac region has been requested. There is insufficient documentation to support that IMRT is expected to provide a superior outcome 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 IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT) (G6015).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the SelectMDx testing services provided on December 3, 2020.  You asked the Plan to pay for the testing services. You say that the testing identifies clinically significant prostate cancer prior to biopsy. The Plan denied your request. The Plan says screening without a valid medical diagnosis is not a 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.  We looked at the file and the rules. In this case, the records do not include signs, symptoms, or a treatment plan related to the testing services. Testing based on a diagnosis code without medical records to corroborate are not covered. Medicare does not cover the testing at issue for screening purposes. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing services provided on December 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the continuation of care with an out-of-network (OON) provider.  You asked the Plan to pre-approve the continuation of care. You say that you have seen this provider in the past and would like to continue to receive care from them. The Plan denied your request. The Plan says there are in-network providers that would be able to provide the medical care you need.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 continuation of care. Our reviewer says that the requested continuation of care with an OON provider is not medically reasonable and necessary. Our physician reviewer found that you state that the provider was in network last year and have already had tests with him and would like to continue treatment. You are a 65-year-old female with a history of hypertension, hypersensitivity lung disease, gastritis, asthma, and family history of coronary artery disease. Your conditions can be adequately evaluated and treated in Plan. There is no specific clinical rational for continued OON services. The review has determined that it is not medically necessary for you to continue to receive care from the OON provider.  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 continuation of care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of care with an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you need physical therapy to gain strength. The Plan denied your request. The Plan says that the services you require can safely be received at a different setting.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve amniotic fluid injections (Q4208, 20610).  You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says the requested treatment is experimental and non-covered.  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 injections. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this therapy is deemed unproven and experimental according current guidelines in the medical literature and the Medicare-approved major drug compendia. 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve amniotic fluid injections (Q4208, 20610).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) procedure to the left side.  You asked the Plan to pre-approve RFA procedure to the left side. You say that you would like this claim reprocessed based on your medical condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that RFA services require at least two medically reasonable and necessary medical branch blocks.  We looked at the file and Medicare rules. Although you have received two medial branch blocks to the right side, none have been received on the left. Therefore, this service cannot be approved. Based on this information, we decided that Medicare rules for coverage of RFA procedure to the left side have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) procedure to the left side.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 30, 2021.  You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that 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 a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on August 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and supplies (K0553).  You asked the Plan to pre-approve a CGM and supplies. You say that you need these items. The Plan denied your request. The Plan says you are not insulin treated.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (K0554) and supplies (K0553).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 29, 2021, to September 27, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee no longer required daily skilled services on the dates of service in this case.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF care have not been met. Specifically, the file does not show that the enrollee received daily skilled services. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from August 29, 2021, to September 27, 2021.