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

 We decided that the Plan has to pre-approve Rituximab injections.  

You asked the Plan to pre-approve Rituximab injections. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says that the requested drug is not medically necessary.  

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Rituximab injections. Our reviewer says that the requested drug is medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has refectory disease as they did not have relief with topical corticosteroids and oral corticosteroids caused an increase in their blood glucose. The reviewer found there are not formal guidelines for which patients qualify for rituximab therapy. The reviewer found that the documentation supports that the Rituximab is medically reasonable and necessary for the enrollee. The reviewer also found that the documentation supports that the Rituximab is safe and effective 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 Rituximab injections have been met. Specifically, the file shows that there are no formal guidelines for which patients qualify for rituximab therapy. Therefore, we decided that the Plan has to pre-approve Rituximab injections.   

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay procedure code 62320 billed for date of service August 23,
2021.
You asked the Plan to pay procedure code 62320 billed for date of service procedure code 62320. You say that
these services were billed correctly so they should be paid. The Plan denied your request. The Plan says the
medical records do not support payment for this service.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include a procedure report that clearly
documents the indications and the medical necessity for the blocks along with the pre and post percent pain
relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
does not include a notation of the percent of pain relief achieved either before or after the injection. Therefore,
we decided that the Plan does not have to pay procedure code 62320 billed for date of service August 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September
20, 2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and
should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for
these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay
for procedure code 62320 billed for date of service September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 13, 2021.  

You asked the Plan to pay for the therapeutic or diagnostic injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not meet Medicare criteria for coverage.  

The Plan must follow Medicare rules. Medicare rules say that all documentation must be maintained in the patient's medical record and made available to the contractor upon request.  

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic or diagnostic injection have not been met. Specifically, the documentation indicates that the medical records were signed long after the date of service. Additionally, the records do not show the pre and post percent (%) pain relief achieved immediately post-injection. Therefore, we decided that the Plan does not have to pay for the therapeutic or diagnostic injection (62320) provided on September 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the transcatheter insertion or replacement of permanent leadless pacemaker (CPT code 33274), for the enrollee.  You asked the Plan to pre-approve the pacemaker. You say that the pacemaker is necessary. The Plan denied your request. The Plan says this service must be needed as part of or following a Food and Drug Administration (FDA) approved study.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pacemaker have not been met. Effective January 18, 2017, the Centers for Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved studies. Leadless pacemakers are non-covered when furnished outside of a CMS approved CED study. Therefore, we decided that the Plan does not have to pre-approve the transcatheter insertion or replacement of permanent leadless pacemaker (CPT code 33274), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) and facet joint injections (64635, 64626 and J3300) provided on January 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit and facet joint injections. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says these services do not meet any exception criteria for out-of-network coverage.  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 the office visit (99213) and facet joint injections (64635, 64626 and J3300) provided on January 5, 2021 by an out-of-network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services you received from a
licensed clinical professional counselor (LCPC) on September 29, 2021.
You asked the Plan to pay for the outpatient mental health services with a LCPC. You say that you believed
this was a contracted provider. You stated that you have depression and need medical help. The Plan denied
your request. The Plan says this provider is not eligible to perform mental health services.
The Plan must follow Medicare rules. Medicare rules say that Medicare only recognizes the following provider
types for outpatient mental health treatment: physicians, clinical psychologists, clinical social workers, clinical
nurse specialists, nurse practitioners, physician assistants, certified nurse-midwives, and independently
practicing psychologists. The provider you saw on September 29, 2021, is a licensed clinical professional
counselor. This provider type is not recognized by Medicare as an eligible outpatient mental health provider.
Furthermore, the Plan's provider directory does not list this provider as contracted with your specific plan.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient mental health services with a LCPC have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services you received from a licensed clinical
professional counselor (LCPC) on September 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on September 13, 2021  You asked the Plan to pay for dental services. You say that this should be covered as an outpatient procedure. The Plan denied your request. The Plan says the services that were provided are 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 pay for dental services provided by an out-of-network provider on September 13, 2021
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for anesthesia (01936), propofol (J2704), lidocaine (J2001), syringe (A4208) and saline solution (J704) provided on July 27, 2020.  You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that these services are inclusive to another procedure or service.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded sufficient evidence to support why these services were denied. The Plan states that these services were denied as inclusive but does indicate to what service these codes are inclusive. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for anesthesia (01936), propofol (J2704), lidocaine (J2001), syringe (A4208) and saline solution (J704) provided on July 27, 2020.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bariatric surgery.  You asked the Plan to pre-approve bariatric surgery. You say that the requested service is a necessity for your care. The Plan denied your request. The Plan says rules for coverage have not been met because the requested service is not medically reasonable or safe.  The Plan follows Medicare rules. Medicare rules say that bariatric surgery is covered for Medicare enrollees who have a body-mass index greater than or equal to 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity.  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 bariatric surgery. Our reviewer says that the requested service is not medically reasonable and necessary in this case. Our physician reviewer found that the case file does not contain documentation that you have been previously unsuccessful with medical treatment for obesity.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bariatric surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve bariatric surgery.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the wound debridement (11042) and complex repair (13101 and 13102) provided on April 21, 2021.  You asked the Plan to pay for the wound debridement (11042) and complex repair (13101 and 13102). You say that the attached records should be reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says CPT code 13101 is included in the global surgery period. The Plan also says that an appropriate modifier was not billed with CPT codes 11042 and 13102 to bypass the edit.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 11042 is a column II code to column I code 13101, and CPT code 13102 is a column II code to column I code 11042. This claim has not been billed with an appropriate modifier to bypass the edits.   In addition, CPT code 15830 has a global period of 90 days. CPT code 13101 was billed within 90 days by the same provider and there is no indication that these services are unrelated. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the wound debridement (11042) and complex repair (13101 and 13102) provided on April 21, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Beovu.  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 step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has exudative age-related macular degeneration with active choroidal neovascularization. She has not tried and failed the Plan's required drug, Avastin. The records do not show that the required drug would be contraindicated or less effective; therefore, Beovu 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Beovu.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 20, 2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection. The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Rivita skin substitute.  

You asked the Plan to pre-approve the Rivita skin substitute. You say that you would like reconsideration because the requested skin substitute is medically necessary. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of the requested supplies.  

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.        

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Rivita skin substitute have not been met. The documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pre-approve the Rivita skin substitute.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the initial hospital care (99221) provided on June 18, 2021.  You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the diagnosis code listed on the claim cannot be billed as the primary diagnosis.  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 99221 is supported in the record. Specifically, there is no applicable Medicare guidance to indicate that diagnosis code Z53.09 can only be billed as a secondary diagnosis code. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor.  Based on this information, we decided that Medicare rules for coverage of the initial hospital care have been met. Therefore, we decided that the Plan has to pay for the initial hospital care (99221) provided on June 18, 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 the drug testing services (G0481) provided on December 1, 2020.  

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was billed with an invalid place of service code.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   

We find that CPT code G0481 is not supported in the record. Specifically, this claim was billed with the laboratory place of service code while the records indicate that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0481) provided on December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99223) provided on June 29, 2021.  You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.   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 initial hospital care. Our reviewer says that CPT code 99223 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that CPT 99223 was the service provided on June 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 initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on June 29, 2021.