Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324).
You asked the Plan to pre-approve Orthovisc. You say that Orthovisc is medically necessary. The Plan denied your request. The Plan says Orthovisc 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 Orthovisc. Our reviewer says that treatment with Orthovisc is not medically necessary. Our physician reviewer found that there are no records documenting pain levels, imaging, or clinical findings. There is no documentation provided indicating that the enrollee had an inadequate response to conservative non-pharmacologic therapy. There is no submitted documentation of referral or orders for physical therapy or durable medical equipment (DME); and no submitted documentation of member participation in physical therapy or use of DME. There is no documentation indicating that the enrollee had an inadequate response to analgesics (for example, acetaminophen) and non-steroidal anti-inflammatory drugs. There is no submitted documentation of actual NSAIDs or other oral analgesic use. The review has determined that the documentation does not support that the Orthovisc is medically reasonable and necessary for the patient. The documentation does not support that Orthovisc is safe and effective for the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Orthovisc (J7324).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety protocols (99072) provided March 5, 2021.
You asked the Plan to pay for the chiropractic services. You say that your medical records fully support and justify billing code 99072. The Plan denied your request. The Plan says CMS considers these services bundled with the services provided to the enrollee on the same date of service and is not eligible for separate reimbursement.
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 the chiropractic services has a bundled relationship with the total episode of care and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies and clinical staff time to perform safety protocols (99072) provided March 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (22899 and C9752). 
 
You asked the Plan to pre-approve the Intracept procedure (22899 and C9752). You say that the requested 
Intracept procedure (22899 and C9752) is medically necessary. The Plan denied your request. The Plan says 
the requested Intracept procedure (22899 and C9752) 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 Intracept procedure (22899 and 
C9752). Our reviewer says that the requested Intracept procedure (22899 and C9752) is not medically 
necessary. Our physician reviewer found the intracept procedure is experimental. More research is needed to 
show safety and efficacy. The requested Intracept procedure is not medically necessary 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 Intracept procedure (22899 and C9752) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the Intracept procedure (22899 and C9752).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cerebral Perfusion Analysis (CTP) scan with computed tomography (0042T).
You asked the Plan to pre-approve the CTP scan. You say that this service is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the coverage indications for this study.
The Plan follows Medicare rules. Medicare rules say that a CTP using automated post-processing software algorithmic analysis is medically reasonable and necessary when certain criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CTP scan. Our reviewer says that the health plan's denial appears appropriate in this case. Our physician reviewer found the record indicates that the enrollee is undergoing evaluation for memory and cognitive deficits.
The elements of the coverage criteria are not satisfied; the requested services cannot be 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 the CTP scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cerebral Perfusion Analysis (CTP) scan with computed tomography (0042T).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee requires skilled nursing services or skilled therapy services on a daily basis. This enrollee does not require the services on an inpatient basis, only 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete 
series of x-rays (D0210) provided on April 13, 2021. 
 
You asked the Plan to pay for the evaluation and x-rays. You say that when you made your appointment the 
provider was in-network but discovered after the care was provided that the provider was no longer contracted 
with the Plan. You feel that they complicated your dental care and feel the Plan should change your benefits. 
The Plan denied your request. The Plan says the provider is not contracted with the Plan. These services are 
covered, and you are responsible for 50% coinsurance for these services as they were provided out-of-network. 
You also may be billed by the provider for any amount billed that exceeds the Plan's maximum allowable fees 
for these 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. The rules also 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 50% coinsurance for 
comprehensive exams and 50% coinsurance for diagnostic x-rays when these services are received from out-of-
network providers. 
 
The provider billed a total of $222 for the dental care: $92 for the comprehensive exam and $130 for the x-rays. 
The Plan's maximum allowed fee for the comprehensive oral exam is $44. This is the amount that a network 
provider would accept as full payment for the service, but out-of-network providers do not have this agreement. 
You may be billed for the difference between what the provider bills and what the Plan pays, which is $48 ($92 
- $44 = $48. In addition, you are responsible for 50% coinsurance on the allowed amount for the service ($44 x 
50% coinsurance = $22). You have been asked to pay $70 for the comprehensive exam ($48 +$22 = $70). This 
means you have been asked to pay the correct amount based on your contract with the Plan. 
 
The Plan's maximum allowed fee for the complete series of x-rays is $77. You may be billed the difference 
between what the provider bills for the service and the Plan's maximum allowed rate, which is $53 ($130 - $77 
= $53). In addition, you are responsible for 50% coinsurance on the allowed amount for the x-rays ($77 x 50% 
coinsurance = $38.50. You have been asked to pay $91.50 for the x-rays ($$53 + $38.50), or a total of $161.50 
for the two services. 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 pay for the comprehensive oral evaluation (D0150) and 
complete series of x-rays (D0210) provided on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee was admitted with bowel obstruction from carcinomatosis. The enrollee is not clinically stable as she
has recently had altered mental status that has not yet been resolved. The enrollee continues to receive acute
care services, and these have not been denied. The medical record does not indicate that the enrollee requires
services that she is not currently receiving but that would be available at the LTACH facility. The elements of
the coverage rules are not satisfied. The requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the core build up (D2950) provided on May 25,
2021.
You asked the Plan to reimburse you for the dental service. You say that you feel you should not have to cover
100% of the bill. You say that the billing representative checked to see that the services were covered. You also
say that the billing representative advised The Plan denied your request. The Plan says core build up is not
listed as a covered service. The Plan also says that the provider did not ask if core buildup was a covered
benefit.
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 core build up is not among those
covered under this benefit. Therefore, we decided that the Plan does not have to reimburse you for the core
build up (D2950) provided on May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.
You asked the Plan to pre-approve medial branch blocks. You say that the requested medial branch blocks are medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested medial branch blocks.
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 medial branch blocks. Our reviewer says that the enrollee does not meet criteria for the requested medial branch blocks. Our physician reviewer found the record indicates that the enrollee has lumbar facet arthropathy of moderate severity present 75% of the time. The pain has been present for more than three months. The record does not contain the results of attempt at conservative treatment including physical therapy. The enrollee received a block in 2018 with 75% relief. The elements of the coverage determination are not satisfied. The requested service cannot be 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 medial branch blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for coronavirus testing (87635) provided on April 8, 2020.
You asked the Plan to pay for coronavirus testing. You say that you did not have the correct insurance information to file timely. The Plan denied your request. The Plan says this claim was filed more than a year after the service was provided.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for coronavirus testing was not filed until April 13, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for coronavirus testing (87635) provided on April 8, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 15, 2021.
You asked the Plan to pay for drug testing. You say that more than 22 drug classes were tested according to the lab report. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the provider has not submitted any clinical records to support this service.
The Plan must follow Medicare rules. Medicare rules say that a provider must furnish to the Plan sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. You did not submit test results to the Plan showing the number of drug classes test. Without supporting records, you have not furnished sufficient records to the Plan to justify payment of code G0483 for testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the probiotics on March 11, 2021.
You asked the Plan to pay for the probiotics. You say that the services are necessary. The Plan denied your request. The Plan says they will overturn some of the services, but not the probiotics.
The Plan must follow Medicare rules. Medicare rules say that certain over the counter items are ineligible for coverage, like probiotics. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of probiotics have not been met. Therefore, we decided that the Plan does not have to pay for the probiotics on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies provided to 
the enrollee on April 8, 2021. 
 
You asked the Plan to pay for CGM supplies. You say that this should be covered by the Plan. The Plan denied 
your request. The Plan says that they have not received information they requested from the provider.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay 
for the continuous glucose monitor (CGM) supplies provided to the enrollee on April 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 20, 
2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes 
will be considered part of the same panel. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT 81479. 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 laboratory services provided to the enrollee on October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded as 99291 provided on 
February 24, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed 
based on the medical records. The Plan denied your request. The Plan says the medical records do not support 
the service 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation
listed in the medical records that supports 30-74 minutes of critical care were provided to the enrollee. Based 
on this information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services coded as 99291 provided 
on February 24, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient rehabilitation services provided 
from January 4, 2021, to January 14, 2021. 
 
You asked the Plan to waive the deductible for outpatient rehabilitation services. You say that you disagree 
with how the charges are because you never paid more than $10. The Plan denied your request. The Plan says 
the claims were processed correctly and you are being charged the correct amount. 
 
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 there is a $500 deductible which applies to outpatient rehabilitation services. 

You received outpatient rehabilitation services from January 4 2021, to January 14, 2021. The record shows 
that you had paid $0 toward the $500 deductible prior to receiving the services. Therefore, you are responsible 
to pay the total deductible amount of $500.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
rehabilitation services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a 
$500 deductible which applies to outpatient rehabilitation services. This cost sharing is a contractual obligation 
that had not been met at the time outpatient rehabilitation services were received on January 4, 2021 to January 
14, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient 
rehabilitation services provided from January 4, 2021, to January 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional home health physical therapy visits. 
 
You asked the Plan to pre-approve 12 additional home health physical therapy visits. You say that this is 
medically necessary. The Plan denied your request. The Plan says the enrollee can be treated with a home 
exercise program. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 12 additional home health physical 
therapy visits. Our reviewer says that the requested home health visits are not medically necessary. Our 
physician reviewer found the records do not show that home health skilled therapy services are required to 
effectively provide treatment, care, or services in order to improve the patient's level of function, or to 
establish/perform a maintenance program to maintain the patient's level of function and/or prevent 
deterioration. The patient is at a high functional level and does not require the ongoing skills of a professional 
therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 12 additional home health physical therapy visits have not been met. Therefore, 
we decided that the Plan does not have to pre-approve 12 additional home health physical therapy visits.