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

We decided that the Plan does not have to pre-approve panniculectomy procedure to remove excessive skin and tissue.

You asked the Plan to pre-approve panniculectomy services. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the coverage criteria for the requested procedure have not been satisfied.

The Plan follows Medicare rules. Medicare rules say that the requested panniculectomy procedure is subject to the criteria listed 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 panniculectomy services. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found that the record indicates that the enrollee has had massive weight loss following gastric bypass and exercise. The record indicates that the enrollee underwent panniculectomy in June 2021. The record indicates that the requested procedure is for body contouring purposes. The record does not indicate that that the panniculus causes chronic intertrigo (dermatitis occurring on opposed surfaces of the skin, skin irritation, infection or chafing) that consistently recurs over 3 months while receiving appropriate medical therapy or remains refractory to appropriate medical therapy over a period of 3 months. The requested service is considered cosmetic. The elements of the coverage criteria are not satisfied. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of panniculectomy services have not been met. Therefore, we decided that the Plan does not have to pre-approve panniculectomy procedure to remove excessive skin and tissue.
Appeal type: Outpatient Therapies
Decision: Unfavorable

e decided that the Plan does not have to pay for the electric stimulation therapy provided on September 24, 2020.
You asked the Plan to pay for the electric stimulation therapy. You say that you have a national contract with the Plan as a network provider. You say that you do not need authorization and the claim should be processed at the in-network level. The Plan denied your request. The Plan says the code is not valid for Medicare billing purposes.
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 97014 is application of a modality to 1 or more areas; electrical stimulation (unattended). We find that CPT code 97014 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Specifically, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for Medicare billing purposes. Therefore, we decided that the Plan does not have to pay for the electric stimulation therapy provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99336) provided on June 17, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 physician services (99336) provided on June 17, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the opioid treatment services rendered on January 10, 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 covered. The Plan must follow Medicare rules. The rules state that a substance abuse facility is not eligible to participate
in Medicare.
We looked at the file and Medicare rules. The file shows that the services were rendered in a substance abuse
facility. Therefore, we decided that the Plan does not have to pay for the opioid treatment services rendered on
January 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow.
You asked the Plan to pre-approve Fluid Flow. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the items/services at issue in this case 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 Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve Fluid Flow.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine
rendered on June 14, 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 covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The
Plan follows the same rules. Records do not show that the enrollee has been injured or directly exposed to any
illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus,
diphtheria, and acellular pertussis (Tdap) vaccine rendered on June 14, 2021.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic knee components described by codes L5845 (Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable) and L5850 (Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist).

You asked the Plan to pre-approve the requested knee components. You say that it is felt that these two codes must be approved in order for the enrollee to get a prosthetic that meets his needs. The Plan denied your request. The Plan says these codes are not used in the Ossur Total Knee 2000 system. These code represent functions that exceed the enrollee's needs.

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 knee components. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the patient has an above knee amputation and qualifies for a standard replacement prosthesis with the current medical records documentation. More information is needed to qualify for the advanced prosthesis at this time. 

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 knee components have not been met. Therefore, we decided that the Plan does not have to pre-approve the prosthetic knee components described by codes L5845 (Addition, endoskeletal, knee-shin system, stance flexion feature, adjustable) and L5850 (Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services provided on April 22, 2021 to May 13, 2021 by an out-of-network (OON) provider.

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 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 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 psychotherapy services provided on April 22, 2021 to May 13, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets the coverage criteria detailed in the Local Coverage Determination (LCD): Respiratory Assist Devices - L33800 for the requested portable ventilator (non-invasive pressure support ventilation). As stated in the LCD: claims for ventilators used to provide Continuous positive airway pressure (CPAP) or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not 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 a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for fibromyalgia testing provided to the enrollee on February 4, 2020.
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. The Plan says it does not appear medically necessary for this test to have been conducted.
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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no specific clinical rationale for the obtained laboratory studies on February 4, 2021. There was no documentation of a face to face encounter with the provider. The review has determined that the services at issue in this case were 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for fibromyalgia testing provided to the enrollee on February 4, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) interpretation and report and emergency room (ER) services rendered on May 30, 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 were not billed correctly.

The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. 

We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate primary diagnosis code. 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 pay for the electrocardiogram (EKG) interpretation and report and emergency room (ER) services rendered on May 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport rendered on January 11, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. The rules say that in the case where the beneficiary was pronounced dead after the ambulance is called but before the ambulance arrives at the scene, providers report the A0428 (BLS) HCPCS code. We looked at the file and Medicare rules. The file shows that the claim was not billed with the required A0428 code and QL modifier. 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 pay for the ambulance transport rendered on January 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries rendered on May 14,
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 covered.

The Plan must follow Medicare rules. The rules say that Medicare has provided limited coverage for procedure
code 93880 and any diagnosis code not listed as supporting medical necessity does not support medical
necessity.

We looked at the file and Medicare rules. Billed diagnosis code R42.0 is not listed as a diagnosis code
supporting medical necessity for procedure code 93880. 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
pay for the duplex scan of extracranial arteries rendered on May 14, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided to the enrollee on November 7, 2020.

You asked the Plan to pay for this genetic testing. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says that based on the Medicare regulations, this service cannot be paid as billed. The Plan states this denial was based on the Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Sequencing Testing in [Solid Tumor] Cancers (A55624), the Medicare Local Coverage Article: Billing and Coding: MolDX: Targeted and Comprehensive Genomic Profile Next Generation Sequencing Testing in Cancer (A55197), the Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), and the Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523).

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 Plans are expected to use Medicare regulations that have a MAC B jurisdiction designation for either the state the enrollee lives in or the state in which the provider is located. The regulations referenced by the Plan do not show MAC B jurisdiction for the state the enrollee lives in or in the state the provider is in and therefore do not apply. This means, the Plan has not substantiated its denial as the appropriate Medicare regulations were not used to determined coverage or coding guidelines. Therefore, we decided that the Plan has to pay for genetic testing provided to the enrollee on November 7, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 24, 2021.

You asked the Plan to pay for the eye refraction. You say that this service was ordered by your physician as a necessary part of a diabetic eye exam. The Plan denied your request. The Plan says Medicare does not cover eye refractions. The Plan offers a supplemental benefit that can cover eye refractions when they are received from a provider in the Plan's routine vision care network as part of a routine (non-medical) eye exam. The exam in this case was provided for medical purposes; the criteria for coverage of an eye refraction are not met.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are performed by a provider within the Plan's specified routine vision care network as part of a routine (non-medical) eye exam. 

We looked at the file and the Plan's rules. You say this eye refraction was part of an eye exam related to diabetes. This means that the eye exam in question is medical in nature and not routine. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on June 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for urinary tract infection testing (87482, 87798, 87150, 87799) provided on July 23, 2021.
You asked the Plan to pay for urinary tract infection testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not supported for the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that in order to be covered, laboratory services must be related to a patient's illness or injury (or symptom or complaint) and ordered by a physician. We looked at the file and Medicare rules. The submitted records do not include a physician order for the laboratory services at issue and do not indicate that the testing was related to any patient symptoms or complaints. Based on this information, we decided that Medicare rules for coverage of urinary tract infection testing have not been met. Therefore, we decided that the Plan does not have to pay for urinary tract infection testing (87482, 87798, 87150, 87799) provided on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00731) provided May 26, 2021.

You asked the Plan to pay for the anesthesia services. You say that the anesthesia services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid diagnosis code.

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 00731 is not supported in the medical record. Specifically, per Local Coverage Article: Billing and Coding: Monitored Anesthesia Care (A57361), K29.70 is not listed as a valid diagnosis code for this service. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (00731) provided May 26, 2021.