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

We decided that the Plan has to pre-approve positron emission tomography (PET) imaging services.
You asked the Plan to pre-approve the PET scan. You say that the requested imaging is needed in order to find
the extent of the enrollee's disease. The Plan denied your request. The Plan says that PET imaging before
treatment of prostate cancer is not medically necessary.
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 scan. Our reviewer says that
the criteria for coverage have been met. Our physician reviewer found the enrollee has prostate cancer and is on
observation with a rising PSA. Ga 68 PSMA-11 is indicated for patients with suspected prostate cancer
metastasis (when cancer cells spread from the place where they first formed to another part of the body) who
are potentially curable by surgery or radiation therapy. Ga 68 PSMA-11 is also indicated for patients with
suspected prostate cancer recurrence based on elevated serum prostate-specific antigen (PSA) levels. Ga 68
PSMA-11 is a radioactive diagnostic agent that is administered in the form of an intravenous injection. The
requested PET scan is considered medically reasonable and necessary in this 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 scan have been met. Therefore, we decided that the Plan has to preapprove positron emission tomography (PET) imaging services. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
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 criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses 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 treat with
insulin. 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 a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an X-Ray examination (71045-26) provided on October 6, 2021.
You asked the Plan to pay for X-Ray exam. You say that this procedure was performed by your provider and
was denied as a duplicate in error. The Plan denied your request. The Plan says that the denial of payment for
this service is correct, because this claim is a duplicate of a claim the Plan already paid.
The Plan must follow Medicare rules. Medicare rules say that for services furnished to hospital patients,
contractors pay for the professional component of identifiable, direct, and discrete diagnostic services such as
the interpretation of diagnostic procedures.
We looked at the file and Medicare rules. The record shows that the Plan received and paid a claim for code
71045 to the servicing hospital. Because this was billed by the hospital, it would reflect the Technical
Component (TC) of the diagnostic procedure. The claim at issue in this case was billed by the radiology
professional; therefore, it reflects the Professional Component (PC) of the diagnostic procedure and is payable
under the fee schedule for physician services. The record does not support that the claim you have billed is a
duplicate or that the Plan has already paid for the exact service at issue in this case. Based on this information,
we decided that Medicare rules for coverage of X-Ray exam have been met. Therefore, we decided that the
Plan has to pay for an X-Ray examination (71045-26) provided on October 6, 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 28, 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 this should have been reported with CPT 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. 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 Comprehensive Genomic Profile (CGP) testing provided to the enrollee on May 28, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, emergency transport
(A0429, A0425) provided on September 6, 2021.
You asked the Plan to pay for ambulance service, basic life support, emergency transport. You say that your
pacemaker failed, and you were too weak to walk to get to the hospital and your wife could not assist you. The
Plan denied your request. The Plan says the ambulance transport was not medically necessary.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would
endanger the patient's health. The Plan follows the same rules.
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 ambulance service, basic life support,
emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our
physician reviewer found that based on the medical records provided your presenting symptoms did not meet
prudent layperson criteria for emergency care. You had a normal physical assessment with stable vital signs,
and you were eating and drinking with a normal blood glucose level, and you were ambulating unassisted at the
time of the transport. There were no signs of an acute illness or injury. Based on the medical records provided
the documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi,
private car, or other type of vehicle) were contraindicated. The documentation does not support that you needed
the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can
provide for safe transport. The documentation does not support hat the ambulance transport met the Medicare
criteria for 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 ambulance service, basic life support, emergency transport have not been met.
Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, emergency
transport (A0429, A0425) provided on September 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a transcutaneous electrical nerve stimulator
(TENS) unit.
You asked the Plan to pre-approve TENS unit. You say that you are appealing with supporting records. The
Plan denied your request. The Plan says the denial of authorization for this device is correct, because this is
being requested for chronic low back pain which is not covered by Medicare.
The Plan follows Medicare rules. Medicare rules state that TENS therapy may be covered under certain
circumstances for treatment of chronic, intractable pain or acute post-operative pain, but is not covered for
chronic low back pain.
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 TENS unit. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested use of a TENS unit. Our physician reviewer
found the enrollee does not have acute post-operative pain. The enrollee has chronic low back pain. The
documentation is not clear that the enrollee's sacroiliac and hip pain are not referred from the chronic low back
pain. The documentation does not reveal that the patient's low back pain is from malignancy or a primary
disease entity or that he is an approved clinical study. The rules state that TENS is covered for chronic,
intractable pain other than chronic low back pain with specific indications including that other appropriate
treatment modalities must have been tried and failed. The guidelines also states that that if this device is used
for chronic low back pain it must be a manifestation of a clearly defined and generally recognizable primary
disease entity such as metastatic spread of cancer to the spine.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TENS unit have not been met. Therefore, we decided that the Plan does not
have to pre-approve use of a transcutaneous electrical nerve stimulator (TENS) unit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve comprehensive oral evaluation (D0150) and extraction services (D7210).  You asked the Plan to pre-approve dental services. You say that these services are medically necessary. The Plan denied your request. The Plan says these services are not covered when they are performed by an oral surgeon.  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 when they are to be performed by an oral surgeon. Therefore, we decided that the Plan does not have to pre-approve comprehensive oral evaluation (D0150) and extraction services (D7210).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0482) provided on January 15, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for drug testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this service was not authorized. The Plan also says that they have confirmed that this is not an ambulance service, emergency and urgently needed, post stabilization care, nor dialysis while outside of the service area. The Plan also says that they have determined that both the referring and attending providers are all non-participating with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on January 15, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided July 7, 2021.
You asked the Plan to pay for code 01992. You say that the service provided was medically necessary. The Plan denied your request. The Plan says the billed code is not supported by the medical records.
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 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 code 01992. Our reviewer says that code 01992 is not supported for payment. Our reviewer found deep sedation was not achieved for these procedures, so code 01992 would not be the appropriate to report, 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 code 01992 have not been met. Therefore, we decided that the Plan does not
have to pay for anesthesia for diagnostic or therapeutic nerve blocks and injections (01992) provided July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the services approved. The Plan
denied your request. The Plan says the criteria for coverage are not met.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tubing extension set (S1015) and infection control supplies
(S8301) provided on July 16, 2021.
You asked the Plan to pay for a tubing extension set and infection control supplies. You say that these items
were requested by the physician. The Plan denied your request. The Plan says these items were not billed with
valid codes.
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 codes S1015 and S8301 are not supported in the medical record. Specifically, these codes
have a status indicator of "I." Medicare uses another code for reporting of, and payment for these services.
Based on this information, we decided that Medicare rules for coverage of a tubing extension set and infection
control supplies have not been met. Therefore, we decided that the Plan does not have to pay for a tubing
extension set (S1015) and infection control supplies (S8301) provided on July 16, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department (ED) services provided on
August 31, 2021, billed with primary diagnosis code E08.649.
You asked the Plan to pay for the ED services as billed. You say that this was billed correctly for medically
necessary services. The Plan denied your request. The Plan says the claim was not billed with a valid primary
diagnosis code.
The Plan follows Medicare rules. Medicare rules say that certain codes are manifestation codes, which require
the code of the etiology of the condition to be reported first.
We asked our coding 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 ED services as billed. Our reviewer says
that this claim is not payable as billed. Our coding reviewer found the provider reported E08.649 as primary
diagnosis. ICD-10 guidelines give direction regarding this diagnosis to code first the underlying
condition. Coding should always be to the highest specification documentation allows. This service would not
be covered, with an incorrect diagnosis coded.
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 ED services as billed have not been met. Therefore, we decided that the Plan
does not have to pay for the emergency department (ED) services provided on August 31, 2021, billed with
primary diagnosis code E08.649.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).  You asked the Plan to pre-approve Vertiflex procedure. You say that the enrollee has failed conservative approahes to treatment and is a good candidate for Vertiflex. The Plan denied your request. The Plan says the
denial of authorization for this service is correct, because Vertiflex is experimental/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 Vertiflex procedure. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental, more research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that you need therapy services to get strong to return
to assisted living which is your primary residence. The Plan denied your request. The Plan says your request
for admission to a skilled nursing facility does not meet the requirements for approval.
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 there are no identifiable skilled
nursing or therapy needs.
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 SNF services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (procedure code 70450) provided to the enrollee on October 16, 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 appropriate modifier was not billed in this case.
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 70450 is a column II code to column I code 70496. 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 imaging services (procedure code 70450) provided to the enrollee on October 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for repair of laceration of tongue, floor of mouth, over 2.6 cm or complex (41252) provided February 5, 2021.
You asked the Plan to pay for code 41252. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says the billed code is not supported for 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. 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 code 41252. Our reviewer says that code 41252 is not supported for payment. Our reviewer found code 41252 is considered to be included as an integral part of a more comprehensive service performed on February 5, 2021, and is not separately reported, nor is it eligible for reimbursement.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 41252 have not been met. Therefore, we decided that the Plan does not
have to pay for repair of laceration of tongue, floor of mouth, over 2.6 cm or complex (41252) provided
February 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 2 sensor.
You asked the Plan to pre-approve a Freestyle Libre 2 sensor. You say that the records provided support the
need for the item in dispute. 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 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
Freestyle Libre 2 sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a
Freestyle Libre 2 sensor.