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

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve the requested services. You say that the enrollee will benefit from proton therapy given his prior cardiac history. The Plan denied your request. The Plan says the standard of care is intensity-modulated radiation therapy.
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 requested services. Our physician reviewer found that the case file provided no actual dosimetric comparison and acknowledges the early stage of disease and intent to treat with low doses, which would generally not strongly support the need for proton therapy. As such, proton therapy is not considered medically necessary for this enrollee with esophageal cancer. The requested proton therapy would not be furnished in accordance with accepted standards of care.
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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to
insufficient evidence of efficacy.
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 device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found this device is experimental. More research is needed to show safety and efficacy.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breast.
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI services. The Plan denied your request. The Plan says that the MRI is being requested to determine the extent of your malignancy, prior to treatment to insure confinement to one area of the breast. The Plan says that there is no documentation showing that the enrollee has signs or symptoms of breast cancer.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found a recent mammogram was negative and breast density was categorized as scattered fibroglandular elements. The enrollee's lifetime risk of developing breast cancer was calculated to be 21.1% using the Tyler-Cuzick model. As such, since the risk is greater than 20%, breast MRI is considered necessary as a screen in addition to annual mammography. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met. Therefore, we decided that the Plan has to pre-approve magnetic resonance imaging (MRI) of the breast.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bronchoscopy services provided on February 5, 2021.

You asked the Plan to pay for the services provided. You say that medical records were provided for support. The Plan denied your request. The Plan says the billed services cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

In this case, the CPT Code Manual definition of code 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage. The claim shows that 3 units of code 31624 was billed. We find that 3 units of CPT code 31624 is not supported in the medical record. Specifically, the records do not show that 3 distinct procedures were provided. Based on this information, we decided that Medicare rules for coverage have not been met.

The CPT Code Manual definition of code 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. We find that CPT code 99152 is not supported in the medical record. Specifically, the record does not show that sedation services were provided that required the presence of an independent trained observer. Therefore, we decided that the Plan does not have to pay for the bronchoscopy services provided on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (84520) provided February 9, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 84520 is not supported in the medical record. Specifically, insufficient records were
provided so support the use of the 91 modifier and a repeat procedure. Based on this information, we decided
that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan
does not have to pay for the lab services (84520) provided February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transforaminal epidural injections.
You asked the Plan to pre-approve transforaminal epidural injections. You say that you are appealing with
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because the Plan has approved 2 transforaminal epidural injections and additional injections are not medically
necessary.
The Plan follows Medicare rules. Medicare rules state that a maximum of 2 levels of transforaminal epidural
injections will be 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 transforaminal epidural injections. Our
reviewer says that the enrollee does not meet the criteria for transforaminal epidural injections beyond the 2 the
Plan already approved. Our physician reviewer found There is no role for a series of injections. Each set of
injections must be evaluated for duration and degree of effectiveness before requesting additional injections.
Therefore, only one set of 2 levels is medically reasonable and necessary and these additional injections are
not.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of transforaminal epidural injections have not been met. Therefore, we decided
that the Plan does not have to pre-approve transforaminal epidural injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0075), the set-up of portable x-ray equipment (Q0092), and the x-ray examinations of the chest (71045 x 2) rendered by the out-of-network (OON) provider on February 9, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location (R0075), the set-up of portable x-ray equipment (Q0092), and the x-ray examinations of the chest (71045 x 2) rendered by the out-of-network (OON) provider on February 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitriptylin for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Amitriptylin for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional home health services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support for a skilled physical therapist to make more home visits at this time.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 based on the medical records provided, there is no documentation that additional skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. The enrollee has had at least seven home health physical therapy treatment sessions thus far. Records indicate her short term therapy goals for gait and balance have been met; she is ambulating 150 feet. The additional therapy is reported to be focused on increasing her endurance. It appears that a home exercise program is indicated at this time. No records from the enrollee's treating physician are included recommending further skilled therapy. 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 additional home health services for the enrollee
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the lumbar spine (72131).
You asked the Plan to pre-approve a CT scan of the lumbar spine. You say that the requested service is a
medical necessity for the enrollee. The Plan denied your request. The Plan says that medical necessity rules
have not been met as the requested service duplicates a prior CT scan in August 2021.
The Plan must follow Medicare rules. Medicare rules say that CT 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 a CT scan of the lumbar spine. Our
reviewer says that the requested service is medically reasonable and necessary in this case. Our physician
reviewer found that the provided documentation demonstrates how the requested study would affect the way
you will manage the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a CT scan of the lumbar spine have been met. Therefore, we decided that the
Plan has to pre-approve a CT scan of the lumbar spine (72131).
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on July 9, 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 99231 (subsequent hospital care) and 64488 (transverse
abdominus plane block). Code 99231 is a column II code with a modifier indicator of 1 when billed with
column I code 64488. Code 99231 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 subsequent hospital care rendered on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the conscious sedation services (D9239 and D9243) provided
on June 9, 2021.
You asked the Plan to pay for the conscious sedation services. You say that you would like reconsideration
because you were given the wrong information by the Plan. The Plan denied your request. The Plan says
conscious sedation is not covered per your contract.
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 pay for the
conscious sedation services (D9239 and D9243) provided on June 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone Cypionate for the enrollee.
You asked the Plan to pre-approve this drug. You say that the patient is stable on this medication. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Testosterone Cypionate for
the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cinvanti and Granisetron.

You asked the Plan to pre-approve the requested drugs. The Plan denied your request. The Plan says routine costs associated with clinical trials are not payable by the Plan.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. 

In this case, you asked the Plan to pre-approve the requested drugs as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Cinvanti and Granisetron.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee will continue to have unplanned readmission if admitted to a lower level of care. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that in this case, the enrollee was admitted to the acute care hospital with an infected dialysis access fistula. The record indicates that the enrollee is improving. He continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Therefore, the requested services are 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tendon surgery services (23410 and 23430) provided on May 4, 2021.
You asked the Plan to pay for surgery services. You say that these were separate procedures performed from the initial procedure of 23472-RT. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these codes are considered inclusive to 23472 and therefore cannot be verified.
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 23410 is repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute. The CPT Code Manual definition of code 23430 is tenodesis of long tendon of biceps.
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 surgery services. Our reviewer says that these codes do not meet the Medicare criteria for payment. Our reviewer found the documentation does not support the use of modifier -59 for these codes, as these procedures were performed in the same anatomical location during the session. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of surgery services have not been met. Therefore, we decided that the Plan does not have to pay for tendon surgery services (23410 and 23430) provided on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.

You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that Aduhelm is not reasonable and necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Aduhelm. Our reviewer says that Aduhelm is not medically reasonable and necessary for the enrollee. Aduhlem is FDA-approved for the enrollee's diagnosis. The documentation does not support that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Aduhelm. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm for the enrollee.