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

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care. 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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing 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 skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the interrogation device evaluations (93297, G2066) rendered by the out-of-network (OON) provider on April 21, 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 interrogation device evaluations (93297, G2066) rendered by the out-of-network (OON) provider on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 4, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the denied codes are not supported in the medical records. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11) Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cystourethroscopy (52356) provided on July 30, 2021.  You asked the Plan to pay for the cystourethroscopy (52356). You say that the member has the right to seek treatment for emergency care regardless of whether the provider participates in the network. You say that the provider expects reimbursement as the reasonable value of services as reflected by the total billed charges. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for that HCPCS/CPT code will be denied.    We find that 2 units of CPT code 52356 are not supported. Specifically, CPT code 52356 has an MUE value of 1. This means that only one unit of 52356 can be billed. Based on this information, we decided that Medicare rules for coverage of 2 units of the cystourethroscopy (52356) have not been met. Therefore, we decided that the Plan does not have to pay for the cystourethroscopy (52356) provided on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the True Metrix test strips (A4253), True Metrix control solution (A4256), and True Plus lancets (A4259), provided on April 10, 2020.  You asked the Plan to pay for the test strips, solution and lancets. You say that the items are medically necessary. The Plan denied your request. The Plan says there was no medical exemption request.  The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test strips, solution and lancets have not been met. Therefore, we decided that the Plan does not have to pay for the True Metrix test strips (A4253), True Metrix control solution (A4256), and True Plus lancets (A4259), provided on April 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the refraction services (92015) provided on September 29, 2021.  You asked the Plan to pay for the refraction services. You say that you believe this service should be covered. The Plan denied your request. The Plan says this service is excluded from coverage by both Medicare and the Plan's contract.  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 during a routine eye exam.  We looked at the file and the Plan's rules. In this case, the refraction services were performed during a medical eye exam as confirmed by your provider. Since this was not a routine vision exam, the refraction services will not be covered. Based on this information, we decided that the Plan's rules for coverage of the refraction services have not been met. Therefore, we decided that the Plan does not have to pay for the refraction services (92015) provided on September 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested services. You say that the enrollee's condition has impacted her quality of life. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.  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 enrollee is being treated for spinal stenosis, lumbar region with neurogenic claudication. She presented with low back pain that radiates to the legs into the feet. Current evidence-based medical guidelines and peer reviewed literature do not fully support the spinal decompression device procedure over the standard lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition. FDA contraindications include spinal instability, scoliosis, obesity, and osteoporosis, and have not been adequately addressed in the medical records. There is no discussion of scoliosis of the lumbar spine, and no documentation of the Cobb angle.  There is no discussion indicating that a DEXA scan has demonstrated the lack of significant osteoporosis in this enrollee. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion Interspinous device at L3-4 and L4-5 is 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical services (procedure code 64421) provided to the enrollee.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this service is not allowed when billed without an appropriate primary procedure 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. In this case, we have confirmed that code 64421 is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (procedure code 64421) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the sedation services coded as 99153 provided on April 16, 2021.  You asked the Plan to pay for the sedation services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim is not eligible for payment based on Medicare billing rules.  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 99153 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; each additional 15 minutes intraservice time (List separately in addition to code for primary service)  We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges. These services were provided in a facility billed with a place of service code of 23. As this code has a PC/TC indicator of 3, the billed code 99153 represents a Technical Component Only Code. There is no separate payment for this service when performed in a facility setting. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the sedation services coded as 99153 provided on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).  You asked the Plan to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). You say that the patient has tried and failed conservative treatment without relief. You say that this procedure is medically necessary and the most effective treatment at this time. The Plan denied your request. The Plan says this does not meet the definition of medical necessity.   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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Intracept Intraosseous Nerve Ablation System is intended to be used in conjunction with radiofrequency generators for the ablation of basivertebral nerves of the L3 through S1 vertebrae for the relief of chronic low back pain of at least six months duration that has not responded to at least six months of conservative care. Our reviewer says that there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.  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 unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752) have not been met. Therefore, we decided that the Plan does not have to pre-approve the unlisted spine procedure (22899) and destruction of intraosseous basivertebral nerve (C9752).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided from July 19, 2021, through August 6, 2021.  You asked the Plan to pay for the chiropractic services. You say that you believe that the Plan should pay for these services. The Plan denied your request. The Plan says they cannot pay for the services as billed with the current diagnosis codes.  The Plan must follow Medicare rules. Medicare rules say that for chiropractic services, the primary diagnosis billed must be subluxation.   We looked at the file and Medicare rules. In this case, the chiropractic services have been billed without a primary diagnosis of subluxation. The Plan has contacted your provider and advised them to resend the claim. Based on this information, we decided that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided from July 19, 2021, through August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Interrogation device evaluation services provided on September 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the Interrogation device evaluation services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 Interrogation device evaluation services provided on September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the surgery services provided on March 8, 2021.  You asked the Plan to pay for the services provided. You say that the services are payable on their own. The Plan denied your request. The Plan says that the services are inclusive to the main procedure.  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 file shows that codes 49203 and 15860 were billed. We looked at the file and the rules. The Plan has not provided Medicare rules that would indicate that the services described by 49203 and 15860 are included in payment for 44120. There is no evidence that the services described by 49203 and 15860 would be provided for all small bowel resection (44120). In this case, it appears that these services were simply provided at the same time as 44120, which does not indicate that they are not separately payable. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan has to pay for the surgery services provided on March 8, 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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve vein treatment services.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that coverage criteria have not been met.  The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins is only covered under certain medical indications.   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 there is satisfactory documentation that the enrollee is experiencing varicose bleeding from the sites that were treated. It is specifically documented that she has had four episodes of bleeding over the past six months. Bleeding is a covered indication for treatment. As there is no evidence of truncal reflux, other treatments such as ablation of truncal veins are not necessary or appropriate. Based on the nature and location of the bleeding varicosities, sclerotherapy would be the only reasonable option. As coverage criteria are met, the requested procedure is both reasonable and medically necessary for the condition in question.  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 been met. Therefore, we decided that the Plan has to pre-approve vein treatment services.      If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the neurology testing services provided on February 4, 2020.  You asked the Plan to pay for the neurology testing services. You say that these services were medically necessary. The Plan denied your request. The Plan says this claim has been filed untimely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  The record shows that a claim for the neurology testing services was not filed until June 16, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the neurology testing services provided on February 4, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on July 7, 2021.  You asked the Plan to pay for the non-emergent ambulance services. You say that you would like reconsideration because the ambulance services provided were medically necessary due to the member's condition. The Plan denied your request. The Plan says this claim was billed with an invalid diagnosis code.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the non-emergent ambulance services. Our reviewer says that the record does not document the member was unable to sit in a chair or be transported by a wheelchair van. Records document no unstable medical conditions requiring on-going medical monitoring during transport. Our physician reviewer found there is no documentation that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.  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 non-emergent ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance services (A0428 and A0425) provided on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline and peer reviewed literature do not fully support the spinal decompression device procedure over the 'gold standard' of lumbar laminectomy. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition of spinal stenosis, lumbar region with neurogenic claudication.  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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.