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

 We decided that the Plan has to pre-approve the ambulance transportation services provided on July 2, 2021.  You asked the Plan to pre-approve the ambulance transportation services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says that the diagnosis codes that the ambulance services have been billed with are not typically performed for a patient/member whose gender is male.  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. In this case, the Plan has denied payment based on the diagnosis codes billed not being appropriate for the enrollee's gender. There are multiple discrepancies in the case file where the Plan states at times the enrollee is male and at times the enrollee is female. It is the burden of the Plan to substantiate their denial with evidence. In this case, the conflicting information fails to substantiate their denial for the ambulance services. Therefore, we decided that the Plan has to pre-approve the ambulance transportation services provided on July 2, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. The enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility and may even need long-term care.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation and the psychotherapy services received on June 1, 2021, June 15, 2021, June 22, 2021, and June 29, 2021.  You asked the Plan to pay for the psychiatric diagnostic evaluation and the psychotherapy services. You say that finding a provider for mental health services is not easy. The Plan denied your request. The Plan says the services received are not payable.  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. Licensed Professional Clinical Counselors (LPCC) are not eligible to bill Medicare. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation and the psychotherapy services received on June 1, 2021, June 15, 2021, June 22, 2021, and June 29, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex device.  You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 pre-approve a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has had imaging that demonstrates minimal central canal or foraminal stenosis.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81455) provided on June 30, 2021.  

You asked the Plan to pay for genetic testing. You say that this is supported in the records. The Plan denied your request. The Plan says this was not necessary.  

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 81455 is targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed.  

We find that CPT code 81455 is not supported in the medical record. Specifically, the record does not include documentation of the results from the testing of 51 or greater genes. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (81455) provided on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services (G0283, 97112, 97016) and compound drugs and administration (J3411, J3415, J3490, J7999, 96372) provided on August 23, 2021.  You asked the Plan to pay for physical therapy services and compound drugs and administration. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy services under State law. The rules also say that beginning in July 2015, claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We looked at the file and Medicare rules. Review of the file and publicly available records, we find that the physical therapy services at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Oklahoma. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed exclusively with J7999, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Based on this information, we decided that Medicare rules for coverage of physical therapy services and compound drugs and administration have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (G0283, 97112, 97016) and compound drugs and administration (J3411, J3415, J3490, J7999, 96372) provided on August 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 1, 2021, through February 22, 2021.  You asked the Plan to pay for the SNF care. You say that you would like this claim reprocessed based on the updated information. The Plan denied your request. The Plan says claims that are sent by fax are not covered.  The Plan must follow Medicare rules. Medicare rules say that the Plan is not permitted to accept claims via fax-imaging.   We looked at the file and Medicare rules. In this case, the Plan is not permitted to process the claim as it came via fax. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 1, 2021, through February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an orthosis (L1971, L3170) provided June 30, 2021.  You asked the Plan to pay for the orthosis. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.    The record does not contain a valid physician order or relevant medical records which support medical necessity for the supplies provided in this case. The medical records provided are from 10 months prior to the written order for the item. The plan was unable to verify the written order. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for an orthosis (L1971, L3170) provided June 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Praluent injections.  You asked the Plan to pre-approve Praluent injections. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Praluent injections are not covered under your Medicare Part B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent injections.   Benefits for Praluent injections may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Bevacizumab (Zirabev).  You asked the Plan to pre-approve Bevacizumab (Zirabev). You say that the requested Bevacizumab (Zirabev) is medically necessary. The Plan denied your request. The Plan says the requested Bevacizumab (Zirabev) is not medically necessary.  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 Bevacizumab (Zirabev). Our reviewer says that the requested Bevacizumab (Zirabev) is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of adenocarcinoma of the colon metastatic to the liver. The record indicates that the requested drug is being used as primary single agent therapy.  The Food and Drug Administration has not stated that the requested drug 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 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 Bevacizumab (Zirabev) have not been met. Therefore, we decided that the Plan does not have to pre-approve Bevacizumab (Zirabev).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the compression stockings provided on June 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the compression stockings. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered benefit when provided by an OON provider.  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 compression stockings provided on June 29, 2021 by an out-of-network (OON) provider.
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 is not medically necessary.  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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon the current level of function, the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented acute or complex rehabilitation nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the rehabilitation needs can be safely met in an alternate and lower intensity setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 drug testing services (G0483) provided on April 5, 2021.  You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support that this testing was medically necessary.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Specifically, the documentation submitted does not include a lab report or medical records. There is insufficient information to determine why this testing was ordered or if it was medically necessary for the treatment of the member's condition. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Retacrit for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there was no provided documentation showing prior use of Retacrit leading to less need of transfusion.  Also, the documentation did not show that Reblozyl has helped this enrollee as required to meet criteria for Retacrit use for this 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (G0481) provided on June 30, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for drug testing. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized or requested by an in-network physician.  

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 drug testing (G0481) provided on June 30, 2021, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department services (99285) provided on August 7, 2021.  You asked the Plan to pay for the emergency department services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim does not include an appropriate primary diagnosis and is not eligible for payment.  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 payment for CPT code 99285 is not supported in the medical record. Specifically, this code has been billed with the primary diagnosis of R65.10 defined as Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction.  In this case, it is required that the underlying condition be sequenced first followed by the manifestation. As this service has not been billed with a primary diagnosis code that represents the underlying condition, payment cannot be made for the services as billed. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services (99285) provided on August 7, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services coded 90834 provided on April 21, 2021.  You asked the Plan to pay for the psychotherapy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  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 90834 is psychotherapy, 45 minutes with patient.     We find that CPT code 90834 is not supported in the medical record. Specifically, the documentation does not support that the provider attempted to consult the attending or primary care physician about the services furnished and documentation the consent or declination date of consultation, and the date of consultations in the enrollee's records. In addition, there is no referring physician listed on the claim. 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 coded 90834 provided on April 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided the Plan does not have to pre-approve a white glass with high gold content porcelain crown (D2750) for the enrollee.

You asked the Plan to pre-approve this service. You say that this dental crown is necessary for the enrollee. The Plan denied your request. The Plan says porcelain crowns coded as D2750 are not listed as a covered benefit. Standard crowns are covered once every 5 years coded as D2751. 

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, code D2750 is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve a white glass with high gold content porcelain crown (D2750).