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

 We decided that the Plan does not have to pre-approve facet joint radiofrequency ablation procedures (64635, 64636 x 2).  You asked the Plan to pre-approve the outpatient services. You say that the requested procedures are medically necessary. The Plan denied your request. The Plan says the enrollee did not have an adequate response to the diagnostic medial branch block.  The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint nerves is considered medically reasonable and necessary for patients who have had at least 2 medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary pain.  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 outpatient services. Our reviewer says that the requested radiofrequency ablation procedures are not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee did not have an adequate response to the diagnostic medial branch blocks (MBB) and left sided radiofrequency ablation (RFA). Therefore, the reviewer found that the requested right-sided multi-level RFAs is not medically necessary or reasonable.  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 outpatient services have not been met. Specifically, the file shows that the enrollee did not have an adequate response to the diagnostic MBB and left sided RFA. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablation procedures (64635, 64636 x 2).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional 28 hours weekly for private duty skilled nursing services.  You asked the Plan to pre-approve additional 28 hours weekly for private duty skilled nursing services. You say that the enrollee required round the clock care due to their medical condition. You also say that the services are medically necessary. The Plan denied your request. The Plan says the additional 28 hours weekly are not medically necessary.  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 additional 28 hours weekly for private duty skilled nursing services. Our reviewer says that an additional 28 hours weekly for private duty nursing services is not medically necessary. Our physician reviewer found the provided documentation shows that the enrollee has skilled needs, long-term care needs and custodial needs due to their medical condition. The reviewer found that while the enrollee requires some level of care 24/7, his skilled nursing needs are intermittent and are expected to be supplemented with non-skilled services. The reviewer found that the documentation does not support that an additional 28 hours per week of skilled nursing care is 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 additional 28 hours weekly for private duty skilled nursing services have not been met. Specifically, the file shows that the necessary care can be provided within the scope of the already approved 84 hours per week. Therefore, we decided that the Plan does not have to pre-approve an additional 28 hours weekly for private duty skilled nursing services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transforaminal epidural injections (64484, 64483).  You asked the Plan to pre-approve the injections. You say that you are in pain and would like it to stop. You also say that this is the only way to relieve your pain. The Plan denied your request. The Plan says the frequency limit has been reached.  The Plan follows Medicare rules. Medicare rules say that there is no role for "series of three" epidurals. Response to each epidural should be determined prior to determining the value of a repeat epidural and the specific methods used for subsequent epidurals.  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 injections. Our reviewer says that the injections are not medically necessary. Our physician reviewer found the record indicates that the enrollee has lumbar radiculopathy and chronic pain syndrome. The record indicates that the enrollee recently underwent right side L4-L5 transforaminal lumbar epidural steroid injection (TFESI), that was not effective. The reviewer found that the provided documentation does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested injections. Therefore, the reviewer found that 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 injections have not been met. Specifically, the file does not show why the enrollee requires additional procedures when the initial one was not effective. Therefore, we decided that the Plan does not have to pre-approve transforaminal epidural injections (64484, 64483).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.  You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that the enrollee is having trouble recognizing symptoms of hypoglycemia and hyperglycemia. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess adherence to their CGM regimen and diabetes treatment plan.   We looked at the file and Medicare rules. The submitted documentation does not indicate that the enrollee performs blood glucose testing at least four times per day, uses insulin with at least three daily injections, and requires frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapy services (97110) provided September 1, 2020.  You asked the Plan to pay for the therapy services. 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. 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 97110 is Therapeutic procedure, 1 or more areas, each 15 minutes.  We find that CPT code 97110 is not supported in the medical record. Specifically, the records do not document how much time was spent on the procedure.   Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided September 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0483) provided October 12, 2020.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 G0483 is drug testing, 22 or more classes.  We find that CPT code G0483 is not supported in the medical record. Specifically, the records do not show 22 or more classes of drugs were tested. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided October 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an endoscopy (43247) provided March 27, 2021.  You asked the Plan to pay for the endoscopy. You say that the services were medically necessary. The Plan denied your request. The Plan says the code cannot be paid 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.  We find that CPT code 43247 is not supported in the medical record. Specifically, CPT code 43247 is inclusive to CPT 43239 which was also billed. Based on this information, we decided that Medicare rules for coverage of the endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for an endoscopy (43247) provided March 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3031) to be provided by an out-of-network provider.  You asked the Plan to pre-approve the foot orthotics. You say that the orthotics are medically necessary. The Plan denied your request. The Plan says there are network providers available.  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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3031) to be provided by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a colonoscopy and endoscopy to be performed in a hospital setting.  You asked the Plan to pre-approve outpatient service in a hospital setting. You say that the enrollee requires these services in a hospital setting due to their existing comorbidities. The Plan denied your request. The Plan says it is not medically necessary for the enrollee to receive these services in a hospital setting.  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 outpatient service in a hospital setting. Our reviewer says that the requested outpatient services to be performed in a hospital setting are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's endoscopic studies are medically necessary. The reviewer also found that the provided documentation does not indicate any reason that it would be necessary for these services to be performed in a hospital setting. Therefore, the request to receive these services in a hospital setting 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 outpatient service in a hospital setting have not been met. Specifically, the file does not show that the enrollee needs to have these services performed in a hospital setting. Therefore, we decided that the Plan does not have to pre-approve a colonoscopy and endoscopy to be performed in a hospital setting.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics (L3020).  You asked the Plan to pre-approve foot orthotics. You say that this would allow the enrollee to be more active. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3020).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospitalization.
You asked the Plan to pay for acute inpatient hospital care. You say that the service was medically necessary. The Plan denied your request. The Plan says that the service was not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospitalization.
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 neuromuscular testing (95937) provided May 27, 2021.  You asked the Plan to pay for the neuromuscular testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim was billed without a valid diagnosis code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code 95937 is not supported in the medical record. Specifically, M48.02 is not listed as a valid primary diagnosis code for this procedure. Based on this information, we decided that Medicare rules for coverage of the neuromuscular testing have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular testing (95937) provided May 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an office consultation and a follow-up visit to be rendered by the out-of-network (OON) provider.  You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.  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 requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office consultation and a follow-up visit to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pediatric-sized power wheelchair (E1239).  You asked the Plan to pre-approve a pediatric-sized power wheelchair. You say that this item is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   The file shows that you do not have a mobility deficit that impairs your participation in MRADLs. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a pediatric-sized power wheelchair (E1239).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient admission provided from September 29, 2020, through October 4, 2020.  You asked the Plan to pay for an inpatient admission. The Plan denied your request. The Plan says the facility did not submit records that prove either of the conditions billed. Multiple attempts at getting additional records were unsuccessful. The records that facility did send are for a different person.  The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.    We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of an inpatient admission. have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from September 29, 2020, through October 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on April 30, 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 hospital outpatient clinic visit (G0463) rendered by the out-of-network (OON) provider on April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (87532 and 87581) provided on June 16, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (87532 and 87581) provided on June 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (74018) provided July 7, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 74018 has a bundled relationship with code 74250. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (74018) provided July 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) rendered by the out-of-network (OON) provider on June 30, 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 office visit (99213) rendered by the out-of-network (OON) provider on June 30, 2021.