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

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve a lumbar MRI. You say that you need this because you have decreased sensation in your legs and increased back pain. The Plan denied your request. The Plan says that this is not medically necessary.
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 a lumbar MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found the records document that you have progressive multilevel disc space loss shown on an x-ray. A physical exam revealed absent Achilles reflexes and diminished patellar reflexes. This abnormal neurological exam is a red flag and constitutes a valid indication for MRI without first attempting a course of physical therapy. 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 lumbar MRI have been met. Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the memory seat program, an alternative switchbox, armrest pouch all coded as K0108 and a power seat elevation system (E2300).
You asked the Plan to pre-approve the power wheelchair accessories. You say that these items are medically necessary. The Plan denied your request. The Plan says these accessories are not covered per Medicare rules.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.
The items at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve the memory seat program, an alternative switchbox, armrest pouch all coded as K0108 and a power seat elevation system (E2300).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve enfortumab (Padcev).
You asked the Plan to pre-approve Padcev. You say that the enrollee was previously on it and did not progress on it. The Plan denied your request. The Plan says the medication is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Padcev. Our physician reviewer found that in this case, the record indicates the enrollee has a diagnosis of metastatic urothelial carcinoma. The record indicates that the enrollee had been on Keytruda and Padcev, but Keytruda was stopped due to treatment emergent side effects. The record indicates a request to restart the combination because of progression on Padcev alone. The Food and Drug Administration has not stated that the requested drug, as being used, is indicated for the enrollee's condition.
The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer journals were submitted for review. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this 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 Padcev have not been met. Therefore, we decided that the Plan does not have to pre-approve enfortumab (Padcev).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on March 22, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that it wasn't your fault that you had to be transferred to a different facility, so you would like the copayment removed. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per trip for ambulance services. You have been asked to pay a $200 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional sclerotherapy.
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. Medicare rules say that venous treatments 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee presents with a painful
lateral right ankle ulcer. There is no improvement with compression. She has numerous cardiovascular risk
factors and pedal pulses are not documented to be palpable. The provider describes concern for peripheral
artery disease and notes that arterial studies are pending but the results of these have not been provided in the
medical record. The presence of peripheral artery disease is a limitation in the coverage criteria. Furthermore,
varicose vein treatments cannot be considered appropriate or medically necessary without determination of
satisfactory arterial perfusion to the lower extremities. The additional sclerotherapy is therefore 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 additional sclerotherapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
You asked the Plan to pre-approve the RFA. The Plan denied your request. The Plan says the coverage criteria
are not met.
The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2)
radiofrequency sessions will be reimbursed per rolling 12 months.
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 RFA. Our reviewer says that the
requested RFA is not medically reasonable and necessary. Our physician reviewer found that the enrollee has
already had 2 RFA sessions within a 12-month period for L3-S1 area. According to the Medicare guidelines:
"For each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12
months." The review has determined that the enrollee does not meet the criteria for the requested 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 RFA have not been met. Therefore, we decided that the Plan does not have
to pre-approve radiofrequency ablation (RFA).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on May 27, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 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 out of network physician services provided to the enrollee on May 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that facet joint injections are not covered when performed after anterior lumbar interbody fusion or ALIF. 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 facet joint injections. Our reviewer says that the requested facet injections are not medically reasonable and necessary. Our physician reviewer found that the enrollee is an 80-year-old female with a history of low back pain, s/p anterior and posterior lumbar spinal fusion and decompression at L3-S1.
Per the coverage criteria, the following are considered not reasonable and necessary and therefore will be denied: Facet joint procedure performed after anterior lumbar interbody fusion or ALIF. The review has determined that the requested facet joint injections are not medically reasonable or necessary according to the coverage criteria established in the LCD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out of network physician services.
You asked the Plan to pre-approve out of network providers. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says this provider is out of 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 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 out of network physician services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on May 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 procedure code 99202 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 99202 (office visit) and 97811 (acupuncture). Code 99202
is a column II code with a modifier indicator of 1 when billed with column I code 97811. Code 99202 was not
billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not
have to pay for the office visit rendered on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture.
You asked the Plan to pre-approve these services. You say that you do not want to take steroids for your neck pain. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the file shows that the services are being requested for the treatment of neck pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided July 6, 2021 to July 7, 2021.
You asked the Plan to pay for the hospital services. You say that you are appealing the denial of payment of the enclosed statement. You were not aware that the hospital was not in network. The Plan denied your request. The Plan says medical necessity cannot be established without medical records.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. The records show that the Plan had made multiple attempts to obtain medical records without success. Based on this information, we decided that Medicare rules for coverage of the hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided July 6, 2021 to July 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on June 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was 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 service 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 this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out-of-network (OON) provider on June 9, 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 you require short-term additional acute care services for ongoing wound care and monitoring for potential COVID-19 complications at this time that can be successfully completed safely at the current facility. There are no services at the LTACH that you require 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 pre-approve stem cell therapy.
You asked the Plan to pre-approve stem cell therapy. The Plan denied your request. The Plan says this is not a covered service.
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 stem cell therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the use of stem cells to treat low back pain is not evidence-based and has been the subject of specific FDA warnings. This request 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 stem cell therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve stem cell therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the cystourethroscopy procedure you had at your urologist's office on May 26, 2021, the emergency room (ER) visit you had on June 8, 2021, the lab services you had on June 17, 2021, the urethroscopy procedure you had at an outpatient hospital facility on July 1, 2021, the cystourethroscopy procedure you had in your urologist's office on July 6, 2021, and the ER visit you had on July 8, 2021.
You asked the Plan to waive the cost sharing for the procedures you had in your urologist's office, the ER visits, the lab services, and the outpatient hospital urethroscopy procedure. You say that you believe that if the stent had been removed earlier, you would not have needed these additional services, so you shouldn't have to pay these copayments. The Plan denied your request. The Plan says you were charged these copayments correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for medical and surgical care in a specialist's office, a $90 copayment for each ER visit, a $5 copayment for lab services, and a $375 copayment for outpatient surgery and services at an outpatient hospital facility. You have been asked to pay a $35 copayment for the procedures you had in your urologist's office, a $90 copayment for each of the ER visits, a $5 copayment for the lab services, and a $375 copayment for the outpatient hospital urethroscopy procedure. These copayments apply regardless of the reason for the services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the cystourethroscopy procedure you had at your urologist's office on May 26, 2021, the emergency room (ER) visit you had on June 8, 2021, the lab services you had on June 17, 2021, the urethroscopy procedure you had at an outpatient hospital facility on July 1, 2021, the cystourethroscopy procedure you had in your urologist's office on July 6, 2021, and the ER visit you had on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 4, 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 procedure code 99152 is 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.
In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes. We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of the start and end time for these services. 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 moderate sedation services rendered on May 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on May 12,
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 procedure code 70450 is 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.
In this case, the CPT Code Manual definition of code 70450 is CT scan of the head/brain.
We find that CPT code 70450 is not supported in the medical record. Specifically, there are no medical records
to support that a CT scan of the head/brain was performed for the billed date of service. 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 computed tomography (CT) scan rendered on May 12, 2021.