Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for drug testing (G0483) provided on June 7, 2021.  You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your request. The Plan says that the records show that only 20 drug classes were tested.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed.  We find that CPT code G0483 is supported in the medical record. Specifically, the record shows that more than 22 drug classes were tested. The classes tested include Alcohol biomarkers; Amphetamines; Antidepressants; serotonergic class; Antidepressants, tricyclic and other cyclicals Antidepressants, not otherwise specified; Antipsychotics, not otherwise specified; Barbituates; Benzodizepines; Buprenorphine; Cannabinoids, natural; Cannabinoids, synthetic; Cocaine; Fentanyls; Gabapentin, non-blood; Heroin metabolite; Ketamine and Norketamine; Methadone; Methylenedioxyamphetamines; Opiates; Opioids and opiate analogs; Oxycodone; Phencyclidine; Pregabalin; Propoxyphene; Sedative Hypnotics (non-benzodiazepines); Skeletal muscle relaxants; Stimulants, synthetic; Tapentadol; and Tramadol. Based on this information, we decided that Medicare rules for coverage of drug testing have been met. Therefore, we decided that the Plan has to pay for drug testing (G0483) provided on June 7, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (63047, 63048) provided on April 5, 2021.  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 63047 is a column II code to column I code 22630. 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. Additionally, we have confirmed that code 63048 is an add-on code. As the primary procedure code in this case, 63047, is not payable, the add-on code is also not payable. Therefore, we decided that the Plan does not have to pay for the services (63047, 63048) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2313, E2377).  You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says upper limb strength and function are adequate for the enrollee to be able to control the power options using their own switches which are included in the allowance of these 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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that you require other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). You do not need  a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. Your strength and function in the upper extremities support that you can control any included  power options through their own individual switches.  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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional accessories for a power wheelchair (E2313, E2377).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the monitored anesthesia care (MAC) rendered on April 2, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that MAC 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the submitted records do not indicate that the enrollee required additional sedation due to contraindications, anxiety and/or fear caused by or relating to the services provided. There is no clinical documentation that the enrollee required additional pain management outside of the topical pain anesthetic that comes standard with this procedure. There is no documentation of a history of high-risk comorbid conditions that required anesthesia. The MAC was 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 pay for the monitored anesthesia care (MAC) rendered on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.  You asked the Plan to pre-approve the SI joint radiofrequency ablation. You say that the records provided support the medical necessity of the requested SI joint radiofrequency ablation. The Plan denied your request. The Plan says research has not proven the requested treatment to be helpful. The Plan says that it is considered experimental and 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 SI joint radiofrequency ablation. Our reviewer says that SI joint radiofrequency ablation is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has sacroilitis. She had 2 sets of left lateral sacral branch diagnostic blocks which gave her 100% pain relief each time. She takes Hydrocodone/Acetaminophen for pain. The requested SI joint radiofrequency ablation services are considered an experimental/ investigational procedure because of the wide variation in efficacy reported in the literature.  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 SI joint radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve sacroiliac (SI) joint radiofrequency ablation.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an x-ray of the knee (73564) provided by an outpatient hospital on July 23, 2021.  You asked the Plan to waive the copayment for an x-ray. You say that you were seen for knee pain and that all care and x-rays were performed at the same clinic. You say you paid a $25 copayment, which is what the Plan indicates is the charge for a specialist; however, you later received a bill for $60. You feel this bill is incorrect and that you should not have to pay. The Plan denied your request. The Plan says the copayment was applied correctly in accordance with your contract with the Plan.   The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay an $85 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies provided in an outpatient hospital setting.   You have been asked to pay an $85 copayment for an x-ray of the knee. X-rays fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. In reviewing the records, it is clear the facility that performed the service is an outpatient hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray of the knee (73564) provided by an outpatient hospital on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on July 1, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the 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 out of network physician services provided to the enrollee on July 1, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

 We decided that the Plan has to waive the copayments for outpatient mental health services provided on April 23, 2021, and June 17, 2021.  You asked the Plan to waive the copayments for the outpatient mental health visits. You say that these services were telehealth visits to adjust your medications.  These were not hospital-based therapy services. The Plan denied your request. The Plan says that you were charged these copayments correctly.  The Plan says that the provider confirmed these services were provided by an outpatient hospital.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for outpatient mental health telehealth services.   The Plan says you must pay a $100 copayment for the outpatient mental health visits in an outpatient hospital facility. We do not find this argument persuasive.  This bill clearly shows that these outpatient mental health services were billed with a modifier -95.  Modifier -95 means that this was a telehealth visit, not an in-person visit.  Your Evidence of Coverage explicitly states that outpatient mental health telehealth services do not have a copayment.  There is no location restriction on outpatient mental health telehealth services in your contract.  It is not appropriate to charge a copayment for an outpatient hospital mental health visit simply because the telehealth services originated in an outpatient hospital location. Therefore, we decided that the Plan has to waive the copayments for outpatient mental health services provided on April 23, 2021, and June 17, 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis.  You asked the Plan to pre-approve Eliquis. You say that it is medically necessary for the enrollee to continue Eliquis as her anticoagulant to avoid stroke in the future. The Plan denied your request. The Plan says Eliquis is a self-administered drug and does not fall under Part B 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 Eliquis.   Benefits for Eliquis 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says a review of the current medical literature indicates that this service is considered
experimental and 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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is experimental. More research is needed to show safety and efficacy of the
procedure to treat low back pain.

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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (63047) provided on December 30, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not
supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We asked our coder 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 services. Our reviewer says that the use of modifier -59 is
not supported by the records provided. Our reviewer found that the operative report does not include
documentation to support code 63047 as a separate and distinct procedure from code 22630 performed during
the same session. Modifier -59 should be used to distinguish a different session or patient encounter, a different
procedure or surgery, a different anatomical site, or a separate injury.

We looked at this coder's review, the file, and Medicare rules. 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 (63047) provided on December 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve endovascular stent repair to be provided by an out-of-network (OON) provider.  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 available 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 provider at issue in this case is not a network provider with the Plan. 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 out-of-network provider is not medically necessary. Our physician reviewer found the records show that you have an abdominal aortic aneurysm that is more than five centimeters in diameter. You are planned for endograft repair surgery. The Plan has approved the procedure with an in-network vascular surgeon. The records do not show that the referral to the out-of-network provider is medically necessary, as the procedure can be adequately performed by the in-network surgeon.  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.   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 services. Therefore, we decided that the Plan does not have to pre-approve endovascular stent repair 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 pay for the crown (D2740), provided on July 21, 2021.  You asked the Plan to pay for the crown. You say that the service should be covered. The Plan denied your request. The Plan says this is not 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 items or services are not among those covered under this benefit. Specifically, the service is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the crown (D2740), provided on July 21, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that medical necessity has not been established due to lack of completing preliminary evaluations of the requested imaging.

The Plan must follow Medicare rules. Medicare rules say that CT 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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the recent ultrasound has shown portal hypertension and increased splenomegaly. Due to their history, this enrollee is at risk for hepatocellular carcinoma. The unintended 45 pound weight loss is very worrisome and in light of increasing splenomegaly a CT of the abdomen and pelvis is appropriate and 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 the scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.

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 leg device to prevent blood clots (E0676).  You asked the Plan to pre-approve the device. You say that you do not want to have issues with deep vein thrombosis. The Plan denied your request. The Plan says this will be statutorily denied as there is no Medicare benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a leg device to prevent blood clots (E0676).