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

We decided that the Plan does not have to pre-approve MRI, any joint of upper extremity; without contrast material(s) (CPT code 73221).
You asked the Plan to pre-approve the MRI. You say that the service is necessary. The Plan denied your request. The Plan says no information was sent in to explain why this test is needed. The Plan states it does not show your provider's notes with details about the current problem and what was found on exam and testing., it does not show details about treatment tried, and your provider must show medical need before this request can be approved.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We looked at the file, and Medicare rules. No information was provided to verify the service meets Medicare criteria. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, any joint of upper extremity; without contrast material(s) (CPT code 73221).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair (K0001), bath/shower chair (E0240), raised toilet seat (E0244), commode chair (E0168), transfer bench (E0247), and sales tax (S9999), provided on July 19, 2021, and August 5, 2021.
You asked the Plan to pay for the standard wheelchair, bath/shower chair, raised toilet seat, commode chair, transfer bench, and sales tax. You say that the items are medically necessary. The Plan denied your request. The Plan says you obtained these items through a provider that is not enrolled in Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the standard wheelchair (K0001), bath/shower chair (E0240), raised toilet seat (E0244), commode chair (E0168), transfer bench (E0247), and sales tax (S9999), provided on July 19, 2021, and August 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cosela for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this drug is helpful for treatment of the health
problem.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found during Cycle 1, all three
studies prohibited primary prophylactic granulocyte-colony stimulating factor (G-CSF) and erythropoiesisstimulating
agent (ESA) use. Both ESAs and prophylactic G-CSF were allowed from Cycle 2 onwards as
clinically indicated. Cosela can only be approved starting in Cycle #2 but cannot be paid in Cycle #1 as G-CSF
was given.
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 drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Cosela for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 2, 2021.
You asked the Plan to pay for the dental service. You say that this appointment was to get a second opinion on
dental work. You say that a crown fell off. You say that in order to proceed with the second opinion, x-rays
needed to be done. You also say that The Plan denied your request. The Plan says bitewing x-rays are covered
once per plan year. The Plan also says that the frequency limit has been exceeded.
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 and bitewing x-rays are listed as
covered, the frequency limit has been exceeded. The record shows that the Plan paid for bitewing x-rays that
you received on July 16, 2021. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays
(D0274) provided on September 2, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from
August 4, 2020, through August 22, 2020, billed with CBPF1.
You asked the Plan to pay for the SNF services as billed. You say that the billed services are supported with the
medical documentation provided. The Plan denied your request. The Plan says these services have been billed
incorrectly based on documentation.
The Plan follows Medicare rules. Medicare rules say that SNF services are billed using a HIPPS code which
has four digits for four case-mix groups 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 pay for the SNF services as billed. Our reviewer
says that the documentation does not support the surgical wound care services as they were billed. Our
physician reviewer found the enrollee was an 86-year-old woman who suffered a fracture of her left femoral
neck. The enrollee underwent a hemiarthroplasty. The enrollee was admitted for acute rehabilitation. Weightbearing
was to be as tolerated. In this case, the clinical records do not support documentation of intervention(s)
to treat or protect the surgical wound for the period August 5, 2022, through August 11, 2022.
We looked at this physician's review, the file, and Medicare rules. As the documentation does not support the
wound care services, the four digit HIPPS code has not been billed correctly. Based on this information, we
decided that Medicare rules for coverage of the SNF services as billed. have not been met. Therefore, we
decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August
4, 2020, through August 22, 2020, billed with CBPF1.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgery services provided on July 23, 2021.
You asked the Plan to pay for the services provided. You say that this provider is the only one who would perform the surgery. The Plan denied your request. The Plan says they cannot pay a provider who is not eligible to participate in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the surgery services provided on July 23, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan/Supartz/Supartz Fx.
You asked the Plan to pre-approve Hyalgan/Supartz/Supartz Fx. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.
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 Hyalgan/Supartz/Supartz Fx. Our reviewer says that the Plan requires a trial of Durolane, Gelsyn-3 and, Synvisc, or Synvisc-One before they will approve the requested drug. In this case, the member has not tried and failed the required drugs. Our physician reviewer found there is no documentation provided indicating 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 Hyalgan/Supartz/Supartz Fx have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan/Supartz/Supartz Fx
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visits (CPT code(s): 99203 and 99213) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that the services are necessary. The Plan denied your request. The Plan says the services are available by a provider in the enrollee's network.
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 the office visits (CPT code(s): 99203 and 99213) to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs skilled nursing because they have been slow to progress with physical therapy in the hospital. You state the enrollee is a fall risk, they have decreased functional mobility and cannot ambulate more than twenty-five (25) feet without assistance. The Plan denied your request. The Plan says the enrollee's records show that they do not require and are not likely to benefit from daily skilled therapy services, and they are not reasonable in terms of duration and quantity. The Plan states the services they require, such as physical therapy services, can safely be received at a different
setting, for example, home with home health, in residential care, or home with close follow-up with the enrollee's doctor.
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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GAE (CPT code(s): 37243, 36247, and 76937), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found geniculate artery embolization and geniculate nerve ablation are experimental for the treatment of knee pain and disorders. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve GAE (CPT code(s): 37243, 36247, and 76937), for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on April 28, 2021.
You asked the Plan to pay for the Iv tubing extension set and the infection control supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
We find that CPT codes S1015 and S8301 are not supported in the medical record. Specifically, these codes have a status code of "I". A status code of I means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the Iv tubing extension set and the infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Iv tubing extension set coded S1015 and the infection control supplies coded S8301 provided on April 28, 2021.
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 coded R0070 provided on July 13, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel to home or nursing
home. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan
says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code R0070 is transportation of portable x-ray equipment and
personnel to home or nursing home, per trip to facility or location, one patient seen.
We find that CPT code R0070 is not supported in the medical record. Specifically, this code has a Professional
Component (PC)/Technical Component (TC) indicator of 3. This indicator identifies stand-alone codes that
describe the technical component (i.e., staff and equipment costs) of selected diagnostic tests for which there is
an associated code that describes the professional component of the diagnostic tests only. Based on this
information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and
personnel to home or nursing home have not been met. 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 coded R0070
provided on July 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom upper arm prosthesis and accessories 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 the requested device has deluxe features that exceed medical need and replaces rather than improves the function of the arm.
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 based on the medical records provided there is no documentation that the MyoPro device at issue in this case meet Medicare criteria for medically necessity. Current clinical guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. 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 a custom upper arm prosthesis and accessories for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of a back mass (21933).
You asked the Plan to pre-approve the removal of a back mass. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not document why this mass must be removed.
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 removal of a back mass. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a non-progressing non-tender poorly circumscribed mass right paraspinal area that becomes less prominent with Trapezuis contracted and does not cause functional limitations. Imaging reports have not been provided. The records do not indicate a consideration of biopsy. The medical records provided are insufficient to determine the medical necessity of the procedure.
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 removal of a back mass have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of a back mass (21933).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 3, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you do not understand the Plan's reason for the denial of payment. You also say that you followed the correct and proper procedures and pay extra for the dental rider to extend basic coverage and emergency dental problems such as this. The Plan denied your request. The Plan says this service exceeds the frequency limitation in your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, problem focused limited oral evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem focused limited oral evaluation (D0140) on August 30, 2021 and your problem focused limited oral evaluation (D0140) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) provided on September 3, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on September 14, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that the service is a Medicare-covered service The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 14, 2021, by an out-of-network (OON) provider.