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

We decided that the Plan does not have to pre-approve the magnetic resonance imaging, spinal canal and contents (72158).
You asked the Plan to pre-approve the MRI. You say that the enrollee's pain is chronic in nature. Since receiving the denial for the MRI, physical therapy has been ordered and the enrollee has been going, noting no improvement. The Plan denied your request. The Plan says the records do not show that the enrollee meets the Medicare criteria.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic back pain. An MRI of the lumbar spine was performed in 2019 and again in 2020 without change. The provided records, however, do not clearly describe the enrollee having recently exhausted physical therapy for their complaints, nor was there evidence of a red flag diagnosis from physical findings or history to justify earlier use of MRI. Therefore, this request for MRI will be considered not medically necessary 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging, spinal canal and contents (72158).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical fluoride treatment (D1208) and intraoral x-rays (D0220, D0230) provided on June 15, 2021.
You asked the Plan to pay for the fluoride and x-rays. You say that you paid your expected copay on the date of service and did not expect to owe additional money for the dental care. The Plan denied your request. The Plan says intraoral x-rays and fluoride treatments are not covered by your dental 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 the topical fluoride treatment (D1208) and intraoral x-rays (D0220, D0230) provided on June 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided for tooth #4 on June 23, 2021.
You asked the Plan to pay for the crown. You say that the crown was medically necessary. The Plan denied your request. The Plan says dental services and procedures that are not directly associated with a dental disease are not covered. The criteria are not met for coverage of this crown.
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. The Plan covers the crown
when there is extensive decay or destruction of the tooth where the tooth cannot be fixed with only a filling. 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 crown. Our reviewer says that the criteria for coverage of a crown on tooth #4 are not met. Our physician reviewer found the provider in this case had noted that tooth #4 was being prepared as an abutment for an upper partial denture in lieu of additional maxillary implants. The provider noted that tooth #4 has an existing two-surface restoration that exhibited crack lines around the filling. While it is reasonable to place a crown on a tooth in preparation for a partial denture, the reimbursement is determined by the Plan's Policy documentation. As the tooth could be restored with a conventional restoration, the Plan's rules dictate that there would not be coverage for the crown on tooth #4. The criteria are not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the crown have not been met. Therefore, we decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) provided for tooth #4 on June 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be improving and should only require short-term additional
acute care services that can safely be completed at the current facility. There are no services at the LTACH that
the enrollee requires that are not already available and covered at the current facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation therapy services coded 97014 provided on April 2, 2021.
You asked the Plan to pay for the electrical stimulation therapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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. Specifically, this code has a status code of "I". A status code of I means that this code is 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 electrical stimulation therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the electrical stimulation therapy services coded 97014 provided on April 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for eyewear provided on July 17, 2021.
You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says you have exceeded the
allowed benefit as the benefit was previously used on June 11, 2020.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers these services every 2 calendar years.
We looked at the file and the Plan's rules. The file shows you have exceeded the allowed eyewear benefit.
Based on this information, we decided that the Plan's rules for coverage of eyewear have not been met.
Therefore, we decided that the Plan does not have to pay for eyewear provided on July 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3rd additional diagnostic block to be performed in conjunction with the first two.
You asked the Plan to pre-approve a 3rd additional diagnostic block. You say that this procedure is medically necessary. The Plan denied your request. The Plan says only two diagnostic blocks are medically reasonable and necessary to be performed on the same day. An additional is not warranted at this time.
The Plan follows Medicare rules. Medicare rules say that one to two levels of diagnostic blocks are usually allowed per session except for unique circumstances. 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 3rd additional diagnostic block. Our reviewer says that the requested 3rd diagnostic block is not medically reasonable and necessary. Our physician reviewer found the review has determined that there is not a unique circumstance supported by medical records that would allow an additional 3rd diagnostic block beyond the two that have already been approved. The requested block 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 a 3rd additional diagnostic block have not been met. Therefore, we decided that
the Plan does not have to pre-approve a 3rd additional diagnostic block to be performed in conjunction with the first two.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the supplies rendered on May 5, 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 a status indicator of I represents a code that is not valid for Medicare purposes, procedure codes with a status indicator of P are bundled/excluded codes, and payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure codes S1015 (intravenous tubing extension set) and S8301 (infection control supplies) have a status indicator of I and is not valid for Medicare purposes. Billed codes A4556 (electrodes, pair), A4557 (lead wires, pair), A4649 (surgical supply, miscellaneous), and A4253 (blood glucose/reagent strips) have a status indicator of P and no separate payment. Billed codes A4550 (surgical trays) and 99072 (additional supplies, materials, and clinical staff time) have a status indicator of B and no separate payment. Therefore, we decided that the Plan does not have to pay for the supplies rendered on May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.

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 services are not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 severe chronic obstructive pulmonary disease (COPD) but there is no documentation of carbon dioxide retention on an arterial blood gas (ABG) study. Medicare does not cover a ventilator when used as bi-level positive airway pressure (BiPAP) therapy. The services are 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 a home ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rezum Procedure (53854).
You asked the Plan to pre-approve the Rezum procedure. You say that you would like reconsideration because the requested procedure is medically necessary. The Plan denied your request. The Plan says the documentation does not show how severe the member's symptoms are.
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 Rezum procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of failure, contraindication or intolerance to at least three months of conventional medical therapy for BPH such as alpha blocker, PDE5 Inhibitor, finasteride/dutasteride and maximum urinary flow rate (Qmax) of =15 mL/s (voided volume greater than 125 cc). 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 Rezum procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Rezum Procedure (53854).
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 you need IRF care for a full recovery. The Plan denied your request. The Plan says you are unstable for active participation in an IRF.
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 that you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 91223, and 81227 provided on June 16, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 81225, 81226, 91223, and 81227 are not supported in the medical record. Specifically, if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. If no CPT code accurately describes the procedure performed, the laboratory may report CPT code 81479 (Unlisted
molecular pathology procedure) with one unit of service or may report multiple individual CPT codes describing the component test results when medically reasonable and necessary. Procedures reported together must be both medically reasonable and necessary (e.g., sequencing of procedures) and ordered by the physician who is treating the enrollee and using the results in the management of the enrollee's specific medical problem. Review of the file shows that more than one CPT code was submitted for the services rendered. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81225, 81226, 91223, and 81227 provided on June 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 11, 2019.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the laboratory services rendered on December 11, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on October 16, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.

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 that the cited drug under consideration is Abilify for which there may be actionable information obtained by pharmocogentic testing, but there is weak evidence supporting such changes and any changes recommended are considered optional.

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 the GeneSight Psychotropic testing provided on October 16, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eylea. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 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 Eylea. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837) provided on January 18, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says there is no documentation of a consultation with the attending physician.
The Plan must follow Medicare rules. Medicare rules say that CPs are required to document a consultation with the primary or attending physician or the attempt to make such a consultation. We looked at the file and Medicare rules. There is no documentation in this record supporting consultation or attempt at consultation was performed. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837) provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (22847) provided on March 10, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 22847 is "Anterior instrumentation; 8 or more vertebral segments". 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 services. Our reviewer says that the use of code 22847 is not supported by the records provided. Our reviewer found that the operative report does not document "anterior instrumentation; 8 or more vertebral segments". Therefore this procedure 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 services have not been met.
Therefore, we decided that the Plan does not have to pay for the services (22847) provided on March 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services provided on July 30, 2020, by an out-of-network (OON) provider.
You asked the Plan to pay for the surgical pathology services. You say that the services were medically necessary and there was not an in-network laboratory that could be used as an alternative. 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. Therefore, we decided that the Plan does not have to pay for the surgical pathology services provided on July 30, 2020, by an out-of-network (OON) provider