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

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service May 21, 
2022. 
 
You asked the Plan to pay for procedure code 99053. The Plan denied your request. The Plan says procedure 
code 99053 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 We find that procedure code 99053 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99053 billed for date of service May 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on January 9, 2022, to January 10, 2022, at the DRG originally billed.

You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the diagnosis codes billed were evaluated, diagnosed, treated, and monitored as part of the daily care plan and can be considered clinically significant. You say that the diagnosis codes are correct and the originally billed DRG should remain unchanged. The Plan denied your request. The Plan says diagnosis codes N17, J96.21 and J96.22 are not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  

In this case, you billed the inpatient services provided with diagnosis codes N17, J96.21 and J96.22 defined as acute renal failure, acute and chronic respiratory failure with hypoxia and acute and chronic respiratory failure with hypercapnia. 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 the inpatient hospital services at the DRG originally billed. Our reviewer says that the documentation does not support the diagnosis codes billed. Our physician reviewer found that although acute renal failure and acute and chronic respiratory failure with hypoxia/hypercapnia are documented during the hospital stay, there is insufficient documentation to clinically support the diagnosis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided on January 9, 2022, to January 10, 2022, at the DRG originally billed.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Panitumumab (J9303).

You asked the Plan to pre-approve Panitumumab. You say that this is medically necessary. The Plan denied your request. The Plan says this medication is not supported for the enrollee's condition.

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 Panitumumab. Our reviewer says that the requested use of Panitumumab is not supported. Our physician reviewer found the enrollee has a diagnosis of metastatic colon cancer with a KRAS gene mutation exon 13. Patients with known KRAS or NRAS gene mutations should not be treated with either Cetuximab or Panitumumab, either alone or in combination with other anticancer agents, because they have virtually no chance of benefit and the exposure to toxicity cannot be justified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Panitumumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Panitumumab (J9303).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 16 routine transportation trips. 
 
You asked the Plan to pre-approve the additional transportation trips. You say that you need additional 
transportation trips for your appointments through the rest of the year. The Plan denied your request. The Plan 
says you have already used up all 24 one-way transportation trips for this calendar year. You have no 
remaining trips available. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year, with a round trip counting as two trips. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve an additional 16 routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G (L8702).

You asked the Plan to pre-approve a MyoPro Motion G. You say that the device is medically necessary. The Plan denied your request. The Plan says there is a lack of professionally published evidence that shows this device meets the standards of good medical practice and is not mainly for convenience. Therefore, it 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 MyoPro Motion G. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the MyoPro is not known to be effective, based on scientific evidence, professional standards, and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.
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 MyoPro Motion G have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro Motion G (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office visit to be provided by an out-of-network (OON) 
provider. 
 
You asked the Plan to pre-approve office visit. You say that you are requesting reconsideration. The Plan 
denied your request. The Plan says for Medicare-covered services, if the enrollee requires specialized services 
that are not available from a provider in our network, contact their Primary Care Physician (PCP) for 
authorization and coordination of care. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair for the enrollee. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there is no medical need for multiple power options. 
 
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 wheelchair. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found that the records do not document the patient performs bladder self-catheterization and is unable 
to transfer independently or that the patient has increased muscle tone or spasticity. The provided records do 
not document the patient has a musculoskeletal condition or the presence of a cast or brace which prevents 90-
degree flexion at the knee, or the patient has significant edema of the lower extremities that requires an 
elevating leg rest. As the power tilt and recline and the power elevating leg rests do not meet criteria for 
coverage, then power wheelchair with multiple power options is not covered. 
 
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 wheelchair have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a group 3 standard power wheelchair for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service January 8, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that you would like this claim to be reconsidered 
for coverage. The Plan denied your request. The Plan says procedure code 97010 is considered bundled and not 
separately payable. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 97010 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 97010 billed for date of service January 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation and procedure to be provided by an out-
of-network (OON) provider. 
 
You asked the Plan to pre-approve a consultation and procedure. You say that you have been authorized to see 
this provider before and that this provider has offered you options and is helping you with a better quality of 
life. The Plan denied your request. The Plan says you must get your care from network providers. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a consultation and procedure to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services covered under the special supplemental 
benefits for the chronically ill (SSBCI). 
 
You asked the Plan to pre-approve services covered under the SSBCI. You say that you were informed your 
attestation papers were incorrectly sent to a wrong fax number which resulted in the denial of benefits. The 
Plan denied your request. The Plan says you do not meet the requirements for the SSBCI program because you 
do not have a noted need for intensive case management, high risk for hospitalization, or an applicable 
diagnosis. 
 
 
 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 there is insufficient 
information in the record to determine if Medicare rules for coverage of services covered under the SSBCI 
have been met. Sufficient information, including an attestation and medical records, have not been provided to 
show you meet the coverage criteria for SSBCI benefits. Therefore, we decided that the Plan does not have to 
pre-approve services covered under the special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 18, 2022. You asked the Plan to pay for the testing services. You say that the testing is consistent with standard of care 
practice guidelines. The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that the testing at issue was not billed with a modifier suitable for payment. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the lab testing services provided on March 18, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 70450 billed for date of service June 2, 2022.

You asked the Plan to pay for procedure code 70450. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for code 70496.

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 70450 is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service June 2, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone.

You asked the Plan to pre-approve Prednisone. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Prednisone. 

Benefits for Prednisone 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).

You asked the Plan to pre-approve the VIA DISC NP procedure. You say that the requested procedure is medically necessary for the enrollee. The Plan denied your request. The Plan says the requested procedure 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 the VIA DISC NP procedure. Our reviewer says that the requested VIA DISC NP procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation to support that the VIA DISC NP procedure at issue in this case meets all Medicare criteria for medically reasonable and necessary for the enrollee. The reviewer found that the Medicare-approved major drug compendia and the current peer-reviewed medical literature contain no documentation to support the use of the VIA DISC NP procedure for treatment of low back pain with lumbar disc degeneration and facet arthropathy. Therefore, the reviewer found that the requested procedure 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 VIA DISC NP procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level (0627T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (29581) provided on February 11, 2022.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment is included in the global surgery payment.

The Plan must follow Medicare rules. Medicare rules say that the Medicare approved amount for global surgery procedures includes payment for services related to the surgery when furnished by the physician who performs the surgery. 

We looked at the file and Medicare rules. Payment for the requested services (29581) is included in the global surgery payment for the procedure (28810) provided on January 14, 2022, which has a 90-day global period. 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 (29581) provided on February 11, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a magnetic resonance imaging of the pelvis (72195) to be rendered 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an MRI of the pelvis. The Plan denied your request. The Plan says that the 
requested provider is not approved for the service at the location requested. The Plan also says that a 
participating provider has been identified in your area, and is covered under your plan. 
 
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. The record shows that you have requested to receive this MRI from an OON 
provider. The Plan denied your request saying this MRI can be rendered by an in-network provider. However, 
the Plan you are enrolled in is a Preferred Provider Organization (PPO), in which you are allowed to receive 
services from both in-network and out-of-network providers. The Plan has not supported why this service 
cannot be rendered by the requested OON provider. Therefore, we decided that the Plan has to pre-approve a 
magnetic resonance imaging of the pelvis (72195) to be rendered by an out-of-network (OON) provider.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a peripheral nerve stimulator. 
 
You asked the Plan to pre-approve a peripheral nerve stimulator. You say that the Plan's denial is unwarranted 
and unsupported by the enrollee's current medical status and is inconsistent with currently accepted medical 
practice. The Plan denied your request. The Plan says an electrical nerve stimulator is not covered for the 
enrollee's condition. 
 
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 peripheral nerve stimulator. Our 
reviewer says that a peripheral nerve stimulator is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the use of a peripheral nerve stimulator for low back pain and/or sacroiliitis 
is considered experimental/ investigational. 
 
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 peripheral nerve stimulator have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a peripheral nerve stimulator.