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

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a lumbar ESI is covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has low back pain with radiculopathy. There is no documentation of a trial and failure of conservative therapy. There is no record of the presence of a four week trial period. The criteria for coverage are not met and the ESI is therefore not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy provided on March 25, 2021.

You asked the Plan to pay for the psychotherapy. You say that the physician provided medically services and the rendered services meet the professional standards of healthcare. You say that the claim should be processed for payment. The Plan denied your request. The Plan says there was no documentation of a consultation with the attending or primary care physician.

The Plan must follow Medicare rules. Medicare rules say that when services are rendered by a Clinical Psychologist and the patient consents, you must attempt to consult their attending or primary care physician about the provided services.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy have not been met. Specifically, the submitted claim does not include a referring provider. Additionally, the record does not document the consent or declination date to consultations or a physician notification method for unsuccessful consultations. Therefore, we decided that the Plan does not have to pay for the psychotherapy provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nerve block services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested treatment is not proven to treat the enrollee's issue.

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 requested services. Our physician reviewer found that the enrollee has a history of chronic back pain, neuropathic abdominal/abdominal wall pain post abdominal surgeries, neuritis and neuralgia. She has been treated with medical therapy, has a spinal cord stimulator, and has undergone multiple bilateral transversus abdominis plane blocks. This request is for an additional bilateral transversus abdominis plane block under ultrasound guidance. A bilateral transversus abdominis plane (TAP) block numbs the abdominal muscles and skin in preparation for surgery. There is insufficient evidence to support the use of peripheral nerve blocks in the treatment of diabetic peripheral neuropathy, peripheral neuropathies caused by other underlying systemic diseases, or peripheral neuropathies causes such as degenerative or idiopathic reasons. The review has determined that the requested nerve block is not indicated for the enrollee's condition. The requested service 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve nerve block services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on December 21,
2020.

You asked the Plan to pay for an electrocardiogram. You say that this is payable. The Plan denied your request.
The Plan says this cannot be paid separately.

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 93010
has a bundled relationship with code 92950 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for an electrocardiogram (93010) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99152) provided on December 10, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
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, we have confirmed that code 99152
has a bundled relationship with code 77263 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the anesthesia services (99152) provided on December 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 23, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 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.
We looked at the file and Medicare rules. After 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 Arizona. 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 properly, payment cannot be made.
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. The office
visit at issue was billed with modifier 25, which is used to report a significant, separately identifiable
Evaluation and Management (EM) service by the same physician or other qualified health care professional on
the same day of a procedure or other service. There is no documentation of any significant, separately
identifiable evaluation unrelated to the treatment provided to the enrollee on this date of service. Based on this
information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we
decided that the Plan does not have to pay for the services provided on March 23, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral breast magnetic resonance imaging (MRI).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have breast implants. The records do not show that you have had a mammogram or are at high risk for breast cancer. The requested MRI is for screening purposes and not medically necessary for the diagnosis or treatment of your clinical 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral breast magnetic resonance imaging (MRI).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested services. You say that you are in pain every day. The Plan denied your request. The Plan says the device is not indicated for your multi-level disease.
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 requested services. Our physician reviewer found that interspinous process stabilization devices are experimental. More research is needed to show safety and efficacy of the devices. Therefore, the requested services are not considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve platelet-rich plasma injections.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that platelet rich plasma injections are covered when specific criteria are met. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that the injections are being requested for the treatment of hip pain from avascular necrosis. This is not a condition for which the platelet rich plasma injections are covered. The services are therefore not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve platelet-rich plasma injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to require critical care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 11, 2021.
You asked the Plan to pay for the laboratory 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 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. 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 laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. In addition, 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 laboratory services provided on February 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an apicoectomy for an anterior tooth (D3410).

You asked the Plan to pre-approve the apicoectomy. You say that you are in extreme pain. You say that you had a root canal that went bad. You say that you should have had a bridge instead of a root canal. You also say that this is messing with your mental health. The Plan denied your request. The Plan says apicoectomy is not listed as a covered service.

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, the requested apicoectomy is not among those covered under this benefit.

Therefore, we decided that the Plan does not have to pre-approve an apicoectomy for an anterior tooth (D3410).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth office visit provided on March 19, 2021.

You asked the Plan to pay for the telehealth office visit. 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 for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. 

A review of the file does not show that the telehealth service was provided in an authorized originating site. Review of the file shows that the visit was billed with a place of service 19 (off campus-outpatient hospital). This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the telehealth office visit provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says the drug is not being prescribed for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Keytruda. Our physician reviewer found that the enrollee has non-small cell lung cancer with metastasis to the bone. The requested use of Keytruda is not FDA-approved for the enrollee's diagnosis. There is no PD-L1 status or driver mutations provided. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. The use is not listed as not indicated, not supported or not recommended in any of the compendia. The documentation does not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve pembrolizumab (Keytruda).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services (G0156) 8 hours per day, 5
nights per week.

You asked the Plan to pre-approve the home health services. You say that your daughter is not your personal
care attendant. You say that your daughter is not live with you. You also say that the requested service is
medically necessary. The Plan denied your request. The Plan says the home health aide services are not
medically necessary.

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. Specifically, the file shows that the home health aide
services are being requested for overnight care. Home health aide services are not medically necessary to sit by
the enrollee nightly while they sleep. Therefore, we decided that the Plan does not have to pre-approve home
health aide services (G0156) 8 hours per day, 5 nights per week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services you received from May 12, 2020, to October 10, 2020.

You asked the Plan to pay for the podiatry services. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails. 

The records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for the podiatry services you received from May 12, 2020, to October 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 25.

You asked the Plan to pre-approve the dental service. You say that the root canal is medically necessary. The
Plan denied your request. The Plan says root canal is excluded from dental coverage.

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, the requested root canal is not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a root canal
(D3310) for tooth # 25.
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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