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

We decided that the Plan has to pay for radiation treatment management (77427) and computed tomography (CT) guidance for placement of radiation fields (77014) provided from March 17, 2021, to March 24, 2021.
You asked the Plan to pay for radiation treatment management and CT guidance. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because the records submitted do not support the codes billed on this claim.
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 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 77427 is radiation treatment management, 5 treatments. The CPT Code Manual definition of code 77014 is computed tomography guidance for placement of radiation therapy fields. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit the relevant medical records for this case. The Plan says that you submitted medical records for review and that these records did not support the codes billed on this claim. You say that you are appealing with supporting medical records. Without the applicable medical records, we cannot determine whether the codes billed on this claim are appropriate for the services rendered. Therefore, the Plan has not shown that its decision to deny payment for these services is correct or justified according to coding guidelines and Medicare rules. Therefore, we decided that the Plan has to pay for radiation treatment management (77427) and computed tomography (CT) guidance for placement of radiation fields (77014) provided from March 17, 2021, to March 24, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says two wheelchairs have been received in the past five years, and the notes do not
show a change in condition to support the need for a new manual wheelchair.
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 the documentation does not reveal evidence of loss, irreparable damage or wear of the current
wheelchair. Additionally, the documentation does not reveal that the wheelchair has been used for over five
years. The criteria for a new manual wheelchair have not been met.
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 manual wheelchair
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on February 22, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says Medicare 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 CPT code.
In this case, the CPT Code Manual definition of code 99135 is Anesthesia complicated by utilization of controlled hypotension (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99135 is a bundled service. There will be no payment amounts for these codes and no separate payment is ever made. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve expandable controller, including all related electronics
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to
expandable controller, including all fasteners, connectors and mounting hardware (CPT code E2313) and
electronic connection between wheelchair controller and two or more power seating system motors, including
all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware
(CPT code E2311), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied
your request. The Plan says the DME is not necessary.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the DME have not been met. The upgraded electronics (expandable
controller, harness and electronic connector to 2 power options) are not medically necessary. They are
necessary when there is a medical need to control power options though the joystick.
The notes do not show a medical need to control the power options through the joystick. The power options can
be controlled using their own switches. These switches can be made any size without asking for a separate
request. They can be made from any material without asking for a separate request. All of this can be done
without the need to use the joystick to control the power features. Therefore, we decided that the Plan does not
have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade
provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all
fasteners, connectors and mounting hardware (CPT code E2313) and electronic connection between wheelchair
controller and two or more power seating system motors, including all related electronics, indicator feature,
mechanical function selection switch, and fixed mounting hardware (CPT code E2311), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (21461) provided on June 18, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 21461 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 (21461) provided on June 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100 colostomy bags for 90 days.
You asked the Plan to pre-approve the extra bags. You say that this is medically necessary. The Plan denied your request. The Plan says this is over the Medicare quantity limit.
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 extra bags. Our reviewer says that the requested extra bags are not considered medically reasonable and necessary in this case. Our physician reviewer found the available records do not support that your ileostomy care requires greater than the usual maximum capacity of the requested colostomy bags of 20 units per months, or 60 per 90 days.
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 extra bags have not been met. Therefore, we decided that the Plan does not have to pre-approve 100 colostomy bags for 90 days.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS)
device, pneumatic compression device (PCD), and multivitamin injections provided on May 17, 2021.

You asked the Plan to pre-approve these medical services. You say that you would like these claims
reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not
covered.

The Plan must follow Medicare rules. Medicare rules say that TENS therapy is covered for chronic low back
pain when part of an approved clinical study. The rules say that PCDs are covered for the treatment of
lymphedema. The rules say that Vitamin B12 injections are not medically necessary.

We looked at the file and Medicare rules. The file shows that the enrollee received TENS therapy, PCD
therapy, and a Vitamin B complex nutria-pharmaceutical blend injection for the treatment of bilateral lower
extremity pain. These services are not covered for this indication. Based on this information, we decided that
Medicare rules for coverage of these medical services have not been met. Therefore, we decided that the Plan
does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) device, pneumatic
compression device (PCD), and multivitamin injections provided on May 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).

You asked the Plan to pre-approve the PET scan. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the Medicare has not been met for the PET scan has not been met.

The Plan must follow Medicare rules. Medicare rules say that PET scans 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 the PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that a 9/29/2021 computed tomography angiography of chest to rule out thoracic aortic aneurysm, polymyalgia rheumatica showed no evidence of aneurysm as well as no significant cardiomegaly, no lymphadenopathy, and no pulmonary emboli; calcific multivessel coronary artery disease. The medical necessity criteria are not met since the enrollee does not have an oncologic condition or listed indication per the requested CPT code and clinical documentation. The clinical value and effectiveness of a whole body PET scan in the setting of ischemic cardiomyopathy has not been demonstrated in the peer-reviewed literature and is not the diagnostic testing standard of care. The review has determined that the member does not have an indication for which a PET Scan can be covered at this time. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging (78816).
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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 patient was admitted for cervical spine decompression and fusion, was discharged
to skilled nursing on September 17, 2021, then discharged home on September 30, 2021. There is ongoing weakness at home. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. In conclusion, there is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services provided on March 1, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was no documented contact with the attending/primary care physician.
The Plan must follow Medicare rules. Medicare rules say that the CP must attempt to consult with the patient's physician within a reasonable time after receiving the consent. If the CP's attempts to consult directly with the physician are not successful, the CP must notify the physician within a reasonable time that he or she is furnishing services to the patient. We looked at the file and Medicare rules. In this case, the records do not show that the CP consulted the attending/PCP. Additionally, there is no referring physician listed on the claim. 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 outpatient mental health services provided on March 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast augmentation surgery (19325).
You asked the Plan to pre-approve a breast augmentation surgery. You say that this requested procedure is not
medically reasonable and necessary. The Plan denied your request. The Plan says this surgery is considered
cosmetic in nature.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are
coverable.
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 breast augmentation surgery. Our
reviewer says that the requested surgery is not medically reasonable and necessary. Our reviewer found that
this case, the record indicates that the enrollee was diagnosed with gender dysphoria in 2017. The record
provided does not indicate current treatment for gender dysphoria or hormonal therapy. The enrollee wishes to
increase breast size from a B cup to C cup. The record provided does not establish the medical necessity and
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria
are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a breast augmentation surgery have not been met. Therefore, we decided that
the Plan does not have to pre-approve a breast augmentation surgery (19325).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on April 14, 2021.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered
service.

The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M for CxBladder
testing are non-covered.

We looked at the file and Medicare rules. In this case, the requested CxBladder test was billed with CPT code
0012M. This is a non-covered service per LCD L35396. 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 CxBladder testing provided on April 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical implant placements.
You asked the Plan to pre-approve the surgical implant placements. You say that implant restorations would improve the patient's ability to deal with a dental prosthesis. The Plan denied your request. The Plan says the implants are denied because there is more than one tooth missing in the arch.
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. The Plan covers the surgical implant placements when the services are medically necessary and reasonable.
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 surgical implant placements. Our reviewer says that the Plan only provides implant restorations where a single implant is to be used, or the implants would be used to retain a complete denture. Our physician reviewer found that there are multiple missing posterior teeth in each arch, and there is the ability to wear a removable partial denture as there are sufficient remaining abutment teeth. Our reviewer says that given the Plan limitations there is no medical necessity for the requested implant restorations. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the surgical implant placements have not been met. Therefore, we decided that the Plan does not have to pre-approve the surgical implant placements.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 21, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The documentation provided does not contain records from the ordering physician, nor documentation of the ordering physician's intent that the testing be performed. 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 provided on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan services coded 93970 provided on May 7, 2021.
You asked the Plan to pay for the duplex scan services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 93970 is duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study.
We find that CPT code 93970 is not supported in the medical record. Specifically, the enrollee had professional interpretation of doppler studies of both legs. The submitted documentation supports one unit of the code billed, which was previously approved by the Plan. There is no additional documentation supporting an additional study which was billed. Based on this information, we decided that Medicare rules for coverage of the duplex scan services have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan services coded 93970 provided on May 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the simethicone (A9270), provided on May 26, 2021.
You asked the Plan to pay for the simethicone. You say that the drug should be covered. The Plan denied your
request. The Plan says this is a self-administered drug.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the simethicone (A9270),
provided on May 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered when performed by an oral surgeon.
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. The Plan covers dental services when they are performed by a participating general dentist. The request is for services with a general surgeon. This provider is not covered under the dental plan. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a dental extraction to be performed by an oral surgeon.