Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) additional ST visits.  You asked the Plan to pre-approve eight (8) additional ST visits. You say that additional ST is medically necessary. The Plan denied your request. The Plan says additional ST is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 eight (8) additional ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. There has been review of the enrollee's condition and treatment plan with caregivers. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of eight (8) additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional ST visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services provided on July 26, 2021.  You asked the Plan to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services. You say that you have tried other treatments and nothing else has helped. The Plan denied your request. The Plan says the services received are not medically necessary.    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 pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have polyneuropathy. You received Scrambler therapy for her pain. The services received are considered an experimental/investigational procedure. Therefore, you did not meet criteria for the services received.  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 transcutaneous electrical modulation pain reprocessing (TEMPR) services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services provided on July 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ascending aorta graft coded as 33863 provided on August 13, 2021.  You asked the Plan to pay for the ascending aorta graft. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this code as billed is not supported in the medical records submitted.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 33863 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the ascending aorta graft. Our reviewer says that the documentation does not support the billing of this code. Our reviewer found the medical records provided do not include sufficient documentation to validate that an ascending aorta graft, with cardiopulmonary bypass, with aortic root replacement using valved conduit and coronary reconstruction was the procedure described and performed on August 13, 2021.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ascending aorta graft have not been met. Therefore, we decided that the Plan does not have to pay for the ascending aorta graft coded as 33863 provided on August 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the salivary surgery procedure coded as 42699 provided on April 29, 2021.  You asked the Plan to pay for the salivary surgery procedure. You say that the documentation supports the service as billed. The Plan denied your request. The Plan says the documentation does not support the services 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, the CPT Code Manual definition of code 42699 is unlisted procedure, salivary glands or ducts.  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the salivary surgery procedure. Our reviewer says that the documentation does not support the services as billed. Our reviewer found the medical records provided do not include sufficient documentation to validate that an unlisted procedure, salivary glands or ducts was performed on April 29, 2021; therefore, this service cannot be verified.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the salivary surgery procedure have not been met. Therefore, we decided that the Plan does not have to pay for the salivary surgery procedure coded as 42699 provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a manual wheelchair and related accessories.  You asked the Plan to pre-approve a manual wheelchair and related accessories. You say that the records provided support the need for the items in dispute. The Plan denied your request. The Plan says the requested wheelchair is for use outside of the home, the enrollee is not a full-time manual wheelchair user, and a backup chair is not considered medically necessary.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The records show that the enrollee has a power wheelchair supplied in 2018 which is used in the home for completion of activities of daily living. The records show that the manual wheelchair is being requested for use outside of the home for shopping, physician appointments, and family activities because the power wheelchair does not allow easy transfer to a vehicle. The items at issue in this appeal is for use outside of the home. Although these items may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and related accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.  You asked the Plan to pre-approve the services. You say that this has been the most effective in treating axial pain. The Plan denied your request. The Plan says the enrollee appears to have radicular pain.    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 that in this case, the enrollee has evidence of radiculopathy. Per the coverage criteria, facet joint injections are indicated only in the absence of untreated radiculopathy or neurogenic claudication (except for radiculopathy caused by facet joint synovial cyst). The facet joint is not the main source of pain. The review has determined that the requested procedures is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Hereditary Assessment for Cardiac Conditions provided to the enrollee on January 12, 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 experimental or investigational services are not 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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has nonobstructive coronary disease.    The primary source records do not support the medical necessity for the requested service or how this service would impact patient management. The requested test appears to be performed for screening purposes. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. 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 pay for a Hereditary Assessment for Cardiac Conditions provided to the enrollee on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a standard wheelchair and a semi-electric hospital bed.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  The Plan must follow Medicare rules. The rules say that a manual wheelchair is covered if there is a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs), and this mobility limitation is not able to be resolved with a cane or walker. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient:  1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or  2. Requires attachments which can only be attached to a hospital bed; AND  3. Requires frequent changes in body position and/or has an immediate need for a change in body position.  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 medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary for you. In terms of the wheelchair, the documentation reveals that you have a mobility limitation, but there are no recent objective progress notes indication an inability to perform MRADLs in the home. There is no indication that the mobility would not be able to be alleviated with a walker. It is not clear that you can safely maneuver. the requested wheelchair in the home or that it will significantly improve MRADL participation in the home. The criteria is not met.  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 standard wheelchair and a semi-electric hospital bed.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 24, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the service is included in the primary procedure.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of the denied codes is:  CPT 80053:  Comprehensive metabolic panel This panel must include the following: Albumin (82040) Bilirubin, total (82247) Calcium, total (82310) Carbon dioxide (bicarbonate) (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Phosphatase, alkaline (84075) Potassium (84132) Protein, total (84155) Sodium (84295) Transferase, alanine amino (ALT) (SGPT) (84460) Transferase, aspartate amino (AST) (SGOT) (84450) Urea nitrogen (BUN) (84520)  CPT 83036:  Hemoglobin; glycosylated (A1C)  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found per the history of the documentation, the enrollee was on home skilled nursing services, and was transported to the emergency department, and then admitted on May 24, 2021. Laboratory testing was ordered and performed on this date of service.  This service would be included with the inpatient services.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a genicular nerve block.  You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks and genicular nerve radiofrequency ablations are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following:  degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. The review has determined that the genicular nerve blocks are considered experimental/ investigational in nature. The requested left genicular nerve block is 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 the block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services provided on July 27, 2021.  You asked the Plan to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services. You say that you have tried other treatments and nothing else has helped. The Plan denied your request. The Plan says the services received are not medically necessary.    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 pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have polyneuropathy. You received Scrambler therapy for her pain. The services received are considered an experimental/investigational procedure. Therefore, you did not meet criteria for the services received.  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 transcutaneous electrical modulation pain reprocessing (TEMPR) services have not been met. Therefore, we decided that the Plan does not have to pay for the transcutaneous electrical modulation pain reprocessing (TEMPR) services provided on July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oncology (prostate) gene expression profile by real-time RT-PCR.  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 are already indications to have a biopsy performed.  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 use of oncology (prostate) gene expression profile by real-time RT-PCR is indicated to determine risk and need for biopsy. As you were at significant risk for prostate cancer given prostate-specific antigen (PSA) with palpable nodule and suspicious magnetic resonance imaging (MRI), oncology (prostate) gene expression profile by real-time RT-PCR is not reasonable or medically necessary and does not add to already known information.  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 oncology (prostate) gene expression profile by real-time RT-PCR.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950).  You asked the Plan to pre-approve a core buildup. You say that you were under the impression that everything was going to be covered and you were not aware you would have to pay for the core buildup. You also say you do not have money to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered service under your 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 a core buildup, including any pins when required (D2950).
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 these services are medically necessary. 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (procedure codes 71046, Q0092, R0070) provided to the enrollee on April 6, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the place of service was inappropriate for the procedure.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of the denied codes is:  CPT 71046:  Radiologic examination, chest; 2 views  Healthcare Common Procedure Coding System (HCPCS) Q0092:  Set-up portable x-ray equipment  HCPCS R0070:  Transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found skilled nursing facilities (SNF) are PPS (Prospective Payment System) and therefore, payment for services rendered would be arranged with the SNF.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (procedure codes 71046, Q0092, R0070) provided to the enrollee on April 6, 2021.