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

We decided that the Plan does not have to pay for the services (62320) provided on August 30, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the provider has not submitted any clinical records to support the medical necessity of this service.

The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient. In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.

The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for the services (62320) provided on August 30, 2021.
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 enrollee will clearly benefit from acute
rehabilitation to optimize her level of functioning prior to returning home. The Plan denied your request. The
Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.

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 that the enrollee is medically stable. He does not need physical medicine and
rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any
active or acute exacerbations of chronic medical conditions. At his current level of function and inability to
tolerate therapies in a skilled nursing facility (SNF), he 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. He will
not be able to tolerate, and benefit from an IRF stay. An IRF admission is not medically necessary based on
lack of medical complexity, and lack of nursing needs and current low activity tolerance. While the enrollee
may benefit from physical therapy, and occupational therapy, the enrollee's rehabilitation needs can be safely
met in an alternate and lower intensity setting such as in a SNF.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (62320) provided August 23, 2021.
You asked the Plan to pay for the injections. You say that the injections were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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. Insufficient clinical documentation was provided to support the billed services. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (62320) provided August 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services (87150) provided on July 30, 2021.  

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.    

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services (87150) provided on July 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Foundation OneCDX comprehensive genomic profiling test provided on October 28, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, per the medical record, there is no evidence that the enrollee has decided or requires chemotherapy for his prostate cancer. The review has determined that the requested genetic testing in this case 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Foundation OneCDX comprehensive genomic profiling test provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implants (D6010) for teeth # 22 and 27.
You asked the Plan to pre-approve the dental services. You say that the services are necessary. The Plan denied your request. The Plan says implants are not listed as covered services.
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 implants are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve implants (D6010) for teeth # 22 and 27.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150).
You asked the Plan to pre-approve the comprehensive oral evaluation. You say that you were not advised that the test was not covered. You also say that you need this debt to be cancelled for you. The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.
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, comprehensive oral evaluation (D0150) is limited to one procedure every three plan years. The record shows that you received a comprehensive oral evaluation (D0150) on December 1, 2020 and your comprehensive oral evaluation (D0150) benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 99053 provided on May 22, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations.  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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.  We looked at the file and Medicare rules. In this case, code 99053 has a Status Code of "B" under the Physician Fee Schedule. The Status Code indicates that payment for covered services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99053 provided on May 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee is unable to care for herself. The Plan denied your request. The Plan says the services the enrollee requires is custodial care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF services. Our physician reviewer found that the enrollee is at a supervision assist level for toileting, contact guard for transfers, minimal assist for dressing, supervision to minimal assist for bathing, and minimal assist for bed mobility. The enrollee does not require the services of a skilled professional nurse to provide medically necessary treatment. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. The enrollee's functional level does not require the services of a qualified therapist to provide medically necessary treatment. She does not require skilled nursing or skilled therapy services on a daily basis. As a practical matter, she may benefit from additional therapies but does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided on March 5,
2021.
You asked the Plan to pay for the ambulatory infusion pump. You say that please reconsider this claim for
medical necessity. The enrollee received services as the physician ordered. Please see attached supporting
documentation. The Plan denied your request. The Plan says the oncologist was paid for the pump inclusive to
CPT 96367 on 03/30/2021.
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 E0781
is a column II code to column I code 96367. 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 the ambulatory infusion pump (E0781) provided on March 5,
2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on August 9, 2021.  You asked the Plan to pay for the ambulance oxygen and oxygen supplies. You say that the enrollee required an ambulance due to being on blood thinners with confusion and needing two liters of oxygen and electrocardiogram (EKG) monitoring. You also say that you would like payment to be reconsidered for this emergency claim. The Plan denied your request. The Plan says this service cannot be billed separately.  The Plan must follow Medicare rules. Medicare rules say that under the ambulance Fee Schedule (FS) oxygen and other items and services provided as part of the transport are included in the FS base payment rate and are generally not separately payable.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance oxygen and oxygen supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance oxygen and oxygen supplies (A0422) provided on August 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 additional transforaminal epidural steroid injections (64484).  You asked the Plan to pre-approve 2 additional transforaminal epidural steroid injections. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for transforaminal steroid injections have not been met.  The Plan must follow Medicare rules. Medicare rules say that is not considered medically reasonable and necessary to perform TFESIs at more than two (2) nerve root levels during the same session.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 additional transforaminal epidural steroid injections have not been met. The case record documents that the Plan has approved 2 initial transforaminal epidural steroid injections. There is no provision in the Medicare rules for additional injections. Therefore, we decided that the Plan does not have to pre-approve 2 additional transforaminal epidural steroid injections (64484).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  

You asked the Plan to pre-approve SNF care. You say that you don't feel strong enough to go home by yourself. You say that you need assistance walking and don't have anyone at home to assist. The Plan denied your request. The Plan says you have no skilled nursing or skilled therapy needs that can only be provided on an inpatient basis.  

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled nursing and therapy services are not 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve a nasopharyngoscopy with dilation of eustachian tube (69706).  You asked the Plan to pre-approve the nasopharyngoscopy services. You say that this procedure is medically necessary for your condition. The Plan denied your request. The Plan says that the requested procedure is considered experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the nasopharyngoscopy services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found there is no gold standard treatment for Eustachian tube dysfunction (ETD), including medical therapy. The first device for balloon dilation of the Eustachian tube (BDET) was approved by the US Food and Drug Administration in 2016. Recent systematic reviews reported that BDET complications were generally few, mild, and self-limited and that BDET was associated with improvement in subjective and objective outcomes for patients with Eustachian tube dysfunction (ETD). The American Academy of Otolaryngology-Head and Neck Surgery Foundation 2019 clinical consensus statement on BDET concluded that BDET was an alternative to tympanostomy tube placement for obstructive ETD and that myringotomy with or without tympanostomy tube placement was not a mandatory prerequisite to BDET. The patient had persistent audiologic findings suggestive of ETD despite previous medical therapy such as steroid nasal sprays, antibiotics, and oral steroids. You underwent nasal endoscopy that showed no evidence of extrinsic obstruction at the nasopharyngeal orifice of the ETD. In summary, the requested BDET meets criteria for being medically necessary and reasonable to treat your ETD.  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 nasopharyngoscopy services have been met. Therefore, we decided that the Plan has to pre-approve a nasopharyngoscopy with dilation of eustachian tube (69706).   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Vyvgart.  You asked the Plan to pre-approve Vyvgart. The Plan denied your request. The Plan says this drug is not medically necessary.  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 Vyvgart. Our reviewer says that Vyvgart is not medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Vyvgart meets Medicare criteria for medically reasonable and necessary for the enrollee's seronegative myasthenia gravis. The Medicare-approved major drug compendia do not cite a Food and Drug Administration indication (or an off label medically accepted use) for Vyvgart for myasthenia gravis without anti-acetylcholine receptor antibodies. There is also no documentation that the Vyvgart meets Medicare criteria for safe and effective for the enrollee's seronegative myasthenia gravis.       We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vyvgart have not been met. Therefore, we decided that the Plan does not have to pre-approve Vyvgart.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on
October 25, 2021.
You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not
been met.
The Plan must follow Medicare rules. Medicare rules say that, in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include the legible signature of the
physician or non-physician practitioner responsible for providing the care to the patient. In addition, the
procedure report should clearly document the indications and the medical necessity for the blocks along with
the pre and post percent pain relief achieved immediately post-injection.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of procedure code 62320 have not been met.
Specifically, the medical records in this case do not meet Medicare's documentation requirements. The record
is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.
Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320)
provided on October 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  

You asked the Plan to pre-approve the Vertiflex procedure. You say that the Vertiflex procedure is medically reasonable and necessary. The Plan denied your request. The Plan says the requested procedure is experimental/investigational.  

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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental in spine surgery. More research is needed before coverage can be approved.  

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-preferred brand for test strips.
You asked the Plan to pre-approve non-preferred supplies. The Plan denied your request. The Plan says you must try and fail preferred testing products.
Medicare rules say that plans can require enrollees to get care from network providers. The rules say that plans may specify brands as preferred.
We looked at the file and the rules. The requested brand for test strips is not a preferred brand. The Plan has preferred brands available for the items at issue in this appeal. We found no exception that would require the Plan to pre-approve a non-preferred brand. Therefore, we decided that the Plan does not have to pre-approve a non-preferred brand for test strips.