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

 We decided that the Plan does not have to pre-approve Synvisc-One.  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 Synvisc-One is 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 you have knee osteoarthritis. The submitted records do not support that you have tried and failed at least three months of conservative therapy and aspiration of the knee. The Synvisc-One is therefore 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 Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.
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 Synvisc-One. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Orthovisc and Monovisc before they will approve the requested drug Synvisc-One. Based on the medical records provided the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Synvisc-One (J7325).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve physical therapy. You say that you would like approval to see this out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on February 22, 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 procedure code 42145 is not supported.  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 42145 is palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty).  We find that CPT code 42145 is not supported in the medical record. Specifically, there is no documentation of a palatopharyngoplasty. Based on this information, we decided that Medicare rules for coverage of these services have not been met.   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 31525 (laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn) and 42890 (limited pharyngectomy). Code 31525 is a column II code with a modifier indicator of 1 when billed with column I code 42890. Code 31525 was not billed with an appropriate modifier to allow for separate payment.  Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-sterile gloves, per 100 (A4927).
You asked the Plan to pre-approve non-sterile gloves. You say that the gloves are needed to take care of the enrollee's g-tube because there is a bad wound underneath the tube and the wound care nurse told you that you need to be wearing gloves when you take care of the wound. The Plan denied your request. The Plan says non-sterile gloves are non-reusable, disposable supply items available in stores without prescription. They are a self-pay item and requested primarily for use by a caregiver, not the enrollee, for hygiene purposes.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve non-sterile gloves, per 100 (A4927).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 24 and 27, and prefabricated abutment (D6056) for teeth # 24 and 27.  You asked the Plan to pre-approve the dental services. You say that you need 2 implants to hold your denture. You say that you cannot eat. You also say that due to your finances and having a lower income, you cannot pay for these. The Plan denied your request. The Plan says implant placement is not listed as a covered service. The Plan says that prefabricated abutment is not listed as a covered service either.  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 dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implant placement (D6010) for teeth # 24 and 27, and prefabricated abutment (D6056) for teeth # 24 and 27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous passive motion exercise device to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve a continuous passive motion exercise device to be provided by an OON provider. You say that the item is necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a continuous passive motion exercise device to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says therapy and care can safely and effectively be delivered in a skilled nursing facility level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for a
stroke and pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal fusion surgery (20930) provided January 27, 2021.
You asked the Plan to pay for the spinal fusion surgery. You say that the procedure was medically necessary.
The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan follows Medicare rules. Medicare rules say that for spinal fusion to be covered the record must
include interpretation and reports for X-rays and other imaging studies.
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 spinal fusion surgery. Our reviewer says
that the records do not support the procedure billed. Our physician reviewer found not enough documentation is
in the records to support the performance of the cervical fusion. More clinical information is needed,
specifically, the results of imaging studies.
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 spinal fusion surgery have not been met. Therefore, we decided that the Plan
does not have to pay for spinal fusion surgery (20930) provided January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on July 12, 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 01922 (anesthesia for non-invasive imaging) and 93313 (transesophageal echocardiogram). Code 01922 is a column II code with a modifier indicator of 1 when billed with column I code 93313. Code 01922 was not billed with an appropriate modifier to allow for separate
payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight chiropractic therapy visits.  You asked the Plan to pre-approve the chiropractic visits. You say that please review and approve visits for the enrollee. The Plan denied your request. The Plan says this appears to be for maintenance for a chronic cervical, lumbar back, sacro-iliac joint and wrist pain which is not a covered Medicare benefit.  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 rules say that Medicare does not cover chiropractic maintenance 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 chiropractic visits Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found LCD L37387 limits chiropractic services (active treatment) to patients with subluxation of the spine as demonstrated by X-ray or physical exam. The clinical documentation does not support that the coverage criteria have been met in this case. It is noted that the enrollee has had 38 visits for the same diagnosis since October, 2019, and has had 16 visits to date during 2021.  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 chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight chiropractic therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on May 26, 2021.
You asked the Plan to pay for these services. You say that you are asking for retroactive prior authorization as you did not have time to get prior authorization prior to rendering the services. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on May 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from November 29, 2020, to December 4, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis code N17.0. 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 use of diagnosis code N17.0 is not supported by the records provided. Our physician reviewer found that while the correspondence noted an isolated blood pressure of 93/43 and stated, "hypotension lasting more than 30 minutes is supportive of ATN," evidence of sustained hypotension greater than 30 minutes during this encounter could not be located. The use of diagnosis code N17.0 is not supported by the records provided. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from November 29, 2020, to December 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the allograft rendered on May 11, 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 procedure code 20930 is not covered.  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 20930 (allograft, morselized, or placement of osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure]) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the allograft rendered on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance.
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you ask for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve therapeutic parenteral drugs (D9612) provided by an out-of-network provider.  You asked the Plan to pre-approve therapeutic parenteral drugs. You say that you would like approval for these services. The Plan denied your request. The Plan says this is not a covered 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 pre-approve therapeutic parenteral drugs (D9612) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
You asked the Plan to pre-approve coverage for special supplemental benefits. You say that you suffer from high blood pressure, osteoarthritis, thyroid, and you have a prosthesis in your left leg. The Plan denied your request. The Plan says you do not meet the required criteria that make you eligible for these special supplementary benefits.
The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special supplemental benefits have not been met. Specifically, we have confirmed that you do not have one of the eligible conditions listed in the Evidence of Coverage. Therefore, we decided that the Plan does not have to pre-approve coverage for special supplemental benefits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95822, 95938, 95940, and A4215) provided on April 29, 2021.
You asked the Plan to pay for the intraoperative neuromonitoring services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that all items and non-physician services furnished to inpatients must be furnished directly by the hospital or billed through the hospital under arrangements. The rules also say that radiology and other diagnostic services furnished to hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the intraoperative neuromonitoring services have not been met. Specifically, this claim includes the technical component for the neuromonitoring services. Payment for the technical component of these services is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the intraoperative neuromonitoring services (95822, 95938, 95940, and A4215) provided on April 29, 2021.