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

We decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance, cervical or thoracic (64490) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance, cervical or thoracic (64491).
You asked the Plan to pre-approve injections. You say that the requested injections are medically necessary. The Plan denied your request. The Plan says the enrollee is not a candidate for facet joint injections as the procedure is not indicated for thoracic spine pain and enrollee is on coumadin.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that the facet injections are requested for thoracic pain. Indications for the requested facet injections include chronic neck or low back pain. The documentation indicates that the enrollee has a history of compression fractures in the thoracic area at T1, T8, T12. The documentation does not support that the requested facet injections are medically necessary as the chronic compression fractures in the thoracic area may explain his pain. Additionally, the provider notes the enrollee needs cardiac clearance due to being on Coumadin and there is no evidence that this procedure will be cleared by cardiology. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance, cervical or thoracic (64490) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance, cervical or thoracic (64491).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an inpatient hospital admission. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan 
denied your request. The Plan says the planned procedure is not on the inpatient only list. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee was approved an elective right total knee arthroplasty procedure. Medical clearance notes describe no unstable conditions or other high risk factors. It is unexpected that the 
patient would require hospital services that would likely cross 2 midnights for this typically ambulatory 
procedure based on the provided documentation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 17, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says preauthorization is required and there was none. The Plan has contracted podiatrists that are accepting new patients.
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 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 physician's services provided on December 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).
You asked the Plan to pre-approve the portable ventilator. You say that this ventilator is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the portable ventilator. Our reviewer says that the portable ventilator is not medically necessary. Our physician reviewer found there is no confirmation of COPD with pulmonary function tests. BiPap has not been tried as an outpatient, with or without AVAPS. Medicare does not cover a home ventilator when used as BiPap. 
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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health skilled nursing visits. 
 
You asked the Plan to pre-approve 5 home health skilled nursing visits. You say that the services are necessary. 
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 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 5 home health skilled nursing visits. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found you have been 
approved for 16 home health skilled nursing visits thus far. Provided records do not document any acute or 
unstable medical conditions or changes in medication or treatment which would necessitate any further skilled 
nursing visits beyond what have already been approved. No medical notes from your treating physician are 
provided documenting a need for additional skilled nursing services. Records indicate you have been educated 
on your disease process and medications and has indicated understanding. An additional skilled nursing visit 
solely for obtaining a blood specimen for laboratory testing (INR) is not eligible for Medicare coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) and services provided in an urgent care center (list in addition to code for service (S9088) provided January 14, 2022.
You asked the Plan to pay for the office visit. You say that please review and preprocess the claim with the records provided. The Plan denied your request. The Plan says this claim is a duplicate claim for services provided by the same provider under the same billing group.
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 find that CPT code 99213 and S9088 is not supported in the medical record. Specifically, documentation received does not indicate that the evaluation and management service was performed more than once on this date of service. S9088 is not a valid code for Medicare purposes per Physician Fee Schedule. This code has a status code of I - not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99213) and services provided in an urgent care center (list in addition to code for service (S9088) provided January 14, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurotrophic receptor tyrosine kinase 1, 2, and 3 (NTRK) translocation analysis and targeted genomic sequence analysis panel.
You asked the Plan to pre-approve NTRK translocation analysis and targeted genomic sequence analysis panel. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve NTRK translocation analysis and targeted genomic sequence analysis panel. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was insufficient high quality evidence supporting its use in this clinical situation leading to significantly different treatment and overall improved outcome to support this request. Therefore, this request for NTRK translocation analysis and targeted genomic sequence analysis panel 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 NTRK translocation analysis and targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pre-approve neurotrophic receptor tyrosine kinase 1, 2, and 3 (NTRK) translocation analysis and targeted genomic sequence analysis panel.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 25, 2021.
You asked the Plan to pay for laboratory services. You say that the tests were requested out of medical necessity to assist in the treatment, prognosis, and diagnosis of their cancer. You say that the clinical evidence supports the testing when the panel includes gene and driver mutations to obtain necessary information for therapeutic decision making and you are requesting coverage. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. 
The enrollee ended Medicare Hospice benefits on December 22, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for laboratory services provided on December 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve right tributary vein phlebectomy (37766).
You asked the Plan to pre-approve right tributary vein phlebectomy (37766). You say that the requested right tributary vein phlebectomy (37766) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested right tributary vein phlebectomy (37766).
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 right tributary vein phlebectomy (37766). Our reviewer says that the enrollee does not meet criteria for the requested right tributary vein phlebectomy (37766). Our physician reviewer found the record indicates that the enrollee has varicose veins on the right and has clinically significant greater saphenous reflux. By rule, the treatment of a tributary in the presence of untreated saphenous reflux is not medically necessary. The elements of the coverage criteria are not satisfied. The requested service is not 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 right tributary vein phlebectomy (37766) have not been met. Therefore, we decided that the Plan does not have to pre-approve right tributary vein phlebectomy (37766).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided by an out-of-network provider from September 7, 2021, through December 10, 2021.
You asked the Plan to pay for chiropractic services. You say that this chiropractor is the only one that has helped for your medical conditions, and you want to continue seeing them. You say that you paid over $1,400 for multiple visits and want to be reimbursed. The Plan denied your request. The Plan says the services remain denied as you self-directed 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 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 chiropractic services provided by an out-of-network provider from September 7, 2021, through December 10, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital care services (99232) provided on September 21 to
September 26, 2021.
You asked the Plan to pay for hospital care services. You say that the enrollee was not in hospice from
September 23, 2021. The Plan denied your request. The Plan says rules for payment have not been met.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on September 22, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital care
services (99232) provided on September 21 to September 26, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for initial hospital care services (99223) provided on February 7, 2022.
You asked the Plan to pay for initial hospital care services. You say that you have provided records to support
the services at issue. The Plan denied your request. The Plan says that rules for payment have not been met
because the charges for the services at issue are incidental to another service.
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 case record contains no information as to in what other service
the enrollee's initial hospital care services were included. It is the Plan's responsibility to substantiate or support
their denial rationale. In this case, the denial rationale has not been substantiated so we must find in your favor.
Therefore, we decided that the Plan has to pay for initial hospital care services (99223) provided on February 7,
2022.
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 acupuncture provided on October 25, 2021.
You asked the Plan to pay for acupuncture. You say that this was denied due to medical necessity and medical records are attached. The Plan denied your request. The Plan says a licensed acupuncturist is a non-covered provider type.
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.
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, a licensed acupuncturist is a non-covered provider type. Therefore, we decided that the Plan does not have to pay for acupuncture provided on October 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on February 16, 2022.
You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says the charges were billed with a medical diagnosis for an eye refraction with a diagnosis of Drusen (degenerative) of macula, left eye. Eye refractions are only covered by your Plan if performed by a participating provider and performed as a routine screening.
The Plan must follow Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. 
We looked at the file and the Medicare rules. Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on February 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visits (99213) provided on October 1, 2021 and November 22, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that she must pay a $30 copayment per visit to a specialist (in office/telehealth). 
The enrollee has been asked to pay $60 ($30 copayment x 2) for the specialist visits provided. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the office visits (99213) provided on October 1, 2021 and November 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.
You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The
Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage
criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a Vertiflex Superion device. Our
reviewer says that the requested items/services are not considered medically reasonable and necessary in this
case. Our physician reviewer found the record provided does not document that the enrollee is not indicated for
operative intervention at no more than two levels. 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 a Vertiflex Superion device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (97032 and 97012), office visit (99212) and x-ray (72083) from February 4, 2021, through September 22, 2021.
You asked the Plan to pay for the physical therapy (97032 and 97012), office visit (99212) and x-ray (72083). The Plan denied your request. The Plan says the chiropractic manipulative treatment (98941) supplies and materials (99070) have been paid. The Plan also says that the physical therapy (97032 and 97012), office visit (99212) and x-ray (72083) remain denied as non-covered chiropractic services.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the physical therapy (97032 and 97012), office visit (99212) and x-ray (72083) from February 4, 2021, through September 22, 2021.