Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214-24) provided on June 29, 2021.
You asked the Plan to pay for an office visit. You say that this was billed with a modifier to indicate it was not related to the enrollee's surgery. The Plan denied your request. The Plan says this is included in the global surgical package.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Modifier "-24" reports an unrelated evaluation and management service by same physician during a postoperative period. The physician may need to indicate that an evaluation and management service was performed during the postoperative period of an unrelated procedure. We find that the billing of modifier -24 on code 99214 is not supported. The submitted records state that this service was a follow up visit after the enrollee's surgery. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214-24) provided on June 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for prolonged evaluation and management services provided on
February 9, 2020, and February 11, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the
documentation did not support the billed service.
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 99356 is prolonged service in the inpatient or observation
setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for
inpatient or observation Evaluation and Management service).
We find that CPT code 99356 is not supported in the medical record. Specifically, the records do not indicate
the enrollee received prolonged physician services above the subsequent hospital care provided. Based on this
information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for prolonged evaluation and management services
provided on February 9, 2020, and February 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 27, 2020, by an
OON provider.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this testing is correct, because this provider is outof-
network with the Plan and the ordering physician is also out-of-network with the Plan.
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 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 laboratory testing provided on November 27,
2020, by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the cervical
spine.
You asked the Plan to pre-approve the MRI services. You say that this is medically necessary. The Plan denied
your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We looked at the file and Medicare rules. In this case, the medical records provided do not support that
conservative treatment has been completed at this time. Based on this information, we decided that Medicare
rules for coverage of the MRI services have not been met. Therefore, we decided that the Plan does not have to
pre-approve the magnetic resonance imaging (MRI) of the cervical spine.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81185) provided on January 4, 2021.
You asked the Plan to pay for laboratory services. You say that this was billed correctly because the sample is taken in the patient's home. The Plan denied your request. The Plan says this was not billed with the correct place of service.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81185) provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on February 26, 2021 to May 5, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you were told that you were covered for chiropractic care and would have to go to an in-network provider. 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 chiropractic services provided on February 26, 2021 to May 5, 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 the gradient compression wrap (A5645).
You asked the Plan to pre-approve the gradient compression wrap. You say that you would like reconsideration
because the wraps are needed to treat edema of the lower extremity. The Plan denied your request. The Plan
says the record shows that your wounds are healed.
The Plan follows Medicare rules. Medicare rules say that a gradient compression stocking or wrap described by
codes A6531, A6532, or A6545 is only covered when it is used in the treatment of an open venous stasis ulcer.
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 gradient compression wrap. Our
reviewer says that you no longer meet criteria for the gradient compression wrap. Our physician reviewer found
the documentation shows that your wounds have healed so the requested wrap is not 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 gradient compression wrap have not been met. Therefore, we decided that
the Plan does not have to pre-approve the gradient compression wrap (A5645).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the retinal imaging you received on June 23, 2021.
You asked the Plan to pay for the retinal imaging. You say that this should be covered. The Plan denied your
request. The Plan says this is not a covered benefit.
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 only routine eye exams, frames, and lenses.
We looked at the file and the Plan's rules. The Plan covers only those routine vision services listed in the
Evidence of Coverage. Retinal imaging is not covered. Based on this information, we decided that the Plan's
rules for coverage of the retinal imaging have not been met. Therefore, we decided that the Plan does not have
to pay for the retinal imaging you received on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for NGS (CPT code(s): 81407, 81479, 81405, 81406, 81286, 81403, 81408, and 81404) provided to the enrollee on May 6, 2021.
You asked the Plan to pay for the genetic testing. You say that the genetic testing is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. Review of the medical records show the enrollee does not have any inherited type of cancers such as breast or ovarian. Also, the enrollee does not have any acquired cancers that are recurrent, relapsed, refractory, metastatic, or advanced stage III or IV. Your request for genetic testing does not meet the requirements for approval of the claim to be paid. Therefore, we decided that the Plan does not have to pay for NGS (CPT code(s): 81407, 81479, 81405, 81406, 81286, 81403, 81408, and 81404) provided to the enrollee on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313)
and electronic connection (2311) for a power wheelchair.
You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say
that the requested items are a medical necessity for you. The Plan denied your request. The Plan says medical
necessity rules for the requested items 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 an expandable controller with harness
and electronic connection. Our reviewer says that the requested items are not considered medically reasonable
and necessary in this case. Our physician reviewer found that there is not a medical need to control the power
options through the joystick. You have 3-4/5 upper limb strength with intact range of motion. You are able to
feed yourself with supervision. Your strength and function are adequate to control the power options using their
own switches which are included in the allowance of the power options approved.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an expandable controller with harness and electronic connection have not been
met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with
harness (E2313) and electronic connection (2311) for a power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 28, 2020.
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. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on March 3, 2021.
You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the medical records show the patient is glucose testing twice a day.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of the CGM supplies have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on March 3, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as a skilled nursing 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 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 hereditary cardiovascular gene panel provided on May 16, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the clinical effectiveness for the testing in asymptomatic individuals has not been demonstrated in peer-reviewed literature.
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. We looked at the file and the rules. It appears the testing may have been ordered by an unsolicited outreach telephone call to the enrollee. The records do not show that this testing was initiated by the enrollee or the enrollee's treating physician. The records do not indicate the results would be used for a specific treatment strategy or medical problem. The test at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular gene panel provided on May 16, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the immunohistochemistry (88344) provided on April 20, 2021.
You asked the Plan to pay for the immunohistochemistry. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says that Medicare does not pay for testing
for screening purposes.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the record indicates that the Plan used lab reports and clinical
information to make their decision. Additionally, the referring provider is in-network, so the Plan has access to
medical records. The documentation submitted does not include the lab report or any clinical information. It is
the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated
so we must find in your favor. Therefore, we decided that the Plan has to pay for the immunohistochemistry
(88344) provided on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that this drug regimen is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.
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 Keytruda. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the enrollee has been diagnosed with metastatic pancreatic cancer. In this case, the enrollee has been heavily pretreated, and the last regimen is Folfox. The provider wishes to have approval based on an American Society of Clinical Oncology abstract regarding of Regorafenib and Keytruda. However, Medicare does not allow abstracts as basis of approval. Furthermore, the requested drug is not supported in Medicare-approved drug compendia or clinical research. The requested use of Keytruda is experimental/investigational for the enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the back brace (L0627), provided on April 29, 2021.
You asked the Plan to pay for the back brace. You say that you should be reimbursed half of what you paid for
the item. The Plan denied your request. The Plan says you purchased the brace through a private seller that is
not eligible to provide services under Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the back brace (L0627), provided on
April 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular gene panel testing provided on March 11, 2021.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing does not meet the requirements for approval.
The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician who is treating the enrollee.
We looked at the file and the rules. In this case, the medical records do not indicate that the results of the testing would be used in the management of a specific medical problem for the enrollee. The medical records do not clearly document the physician's intent for the testing to be performed. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular gene panel testing provided on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your
request. The Plan says this procedure has not been shown to be safe or helpful.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with
neurogenic claudication. The record indicates that the enrollee has moderate to severe central spinal stenosis at
multiple levels. The record does not indicate that the enrollee is not indicated for operative treatment at more
than two levels. 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 the device have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency anesthesia services rendered on March 8, 2020.
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 99140 is not separately payable.
The Plan must follow Medicare rules. The rules say that 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 code 99140 (emergency anesthesia services) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia services rendered on March 8, 2020.