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

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve Intracept. You say that this procedure fills a treatment gap for enrollees who do not receive adequate relief from traditional conservative methods and do not have instability to indicate that fusion is the appropriate treatment. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence of the efficacy of Intracept.  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 Intracept. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure remains experimental for lower back pain. More research is needed to show its safety and efficacy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis coded 81345 provided on June 28, 2021.  You asked the Plan to pay for the TERT gene analysis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.    The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code the TERT gene analysis is a column II code to column I code 81345 for 0089U. 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 TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis coded 81345 provided on June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 064.
You asked the Plan to pay for the inpatient hospital services billed with DRG 064. You say that you would like the previously denied claim to be reprocessed for benefits. The Plan denied your request. The Plan says DRG 064 is not supported as the diagnosis of unspecified severe protein-calorie malnutrition.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with secondary diagnosis code, E43, defined as unspecified severe protein-calorie malnutrition. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital services billed with DRG 064. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found the documentation provided did not reflect evidence of phenotypic, etiologic characteristics or resource utilization consistent with a diagnosis of severe malnutrition. Our reviewer also found that the medical records did not support the billing of unspecified severe protein-calorie malnutrition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services billed with diagnosis related group (DRG) code 064.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99232 provided on June 10, 2021 and June 11, 2021.
You asked the Plan to pay for the subsequent hospital care 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, we have confirmed that code 99232 for the subsequent hospital care services is a column II code to column I code 99233. This claim for date of service June 11, 2021 has not been billed with an appropriate modifier to bypass the edit. Review of the file shows that the services billed for date of service June 10, 2021 was a duplicate claim to services previously paid by the Plan. This service is not separately payable. 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 subsequent hospital care services coded 99232 provided on June 10, 2021 and June 11, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve use of pegfilgrastim.  You asked the Plan to pre-approve pegfilgrastim. You say that the enrollee has neutropenia due to her chemotherapy. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the record does not show that the enrollee had a fever and very low white blood cell count in the past.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 pegfilgrastim. Our reviewer says that the enrollee meets Medicare criteria for the requested use of pegfilgrastim. Our physician reviewer found the enrollee's risk of neutropenic fever is greater than 20% based on age, prior regimen, and current regimen. Pegfilgrastim is Food & Drug Administration (FDA) approved for this diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pegfilgrastim have been met. Therefore, we decided that the Plan has to pre-approve use of pegfilgrastim.   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 pay for the Face Down Recovery System provided on April 27, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the Face Down Recovery System. You say that Medicare covers the recovery system, and it is medically necessary for your recovery from eye surgery. The Plan denied your request. The Plan says the provider is out-of-network.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.   The requested provider in this case is not a network provider with the Plan. 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 the Face Down Recovery System provided on April 27, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve occipital nerve block injections.
You asked the Plan to pre-approve occipital nerve block injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because these injections are not intended for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve occipital nerve block injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no history of acute headaches or clinical evidence that this procedure will provide symptom relief. This will not change short or long-term care and will lead to futile care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occipital nerve block injections have not been met. Therefore, we decided that the Plan does not have to pre-approve occipital nerve block injections
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric (psych) admission provided from July 14, 2021, to July 21, 2021.
You asked the Plan to pay for the inpatient psych admission. You say that the services were medically necessary. The Plan denied your request. The Plan says the inpatient psychiatric services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient psych admission. Our reviewer says that the inpatient psych services were not medically necessary. Our physician reviewer found The provided documentation does not indicate that the enrollee required inpatient mental health treatment beyond the dates in question as noted above as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. The reviewer found that it did not appear that active treatment was taking place beyond the date in question. The reviewer also found that it did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Therefore, the reviewer found that the inpatient psych services were 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 inpatient psych admission have not been met. Specifically, the file shows that the enrollee was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. Therefore, we decided that the Plan does not have to pay for the inpatient psychiatric (psych) admission provided from July 14, 2021, to July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for prolotherapy treatments provided on April 27, 2021.
You asked the Plan to pay for prolotherapy treatments. 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
because the services at issue are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that the medical effectiveness of prolotherapy has not
been verified by scientifically controlled studies. Based on this information, we decided that Medicare rules for
coverage of prolotherapy treatments have not been met. Therefore, we decided that the Plan does not have to
pay for prolotherapy treatments provided on April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99204 provided on April 19, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 99204 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter.
We find that CPT code 99204 is not supported in the medical record. Specifically, this service is for a new patient. The documentation shows that the enrollee had a previous office visit by this provider in the same specialty on March 27, 2021. This means this new patient code is not supported by the documentation. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99204 provided on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Radiologic examination (71045) and the Computed tomography (74177) provided on April 23, 2021.  You asked the Plan to pay for codes 71045 and 74177. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the billing of duplicate claims.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file, the Plan's contract and Medicare rules. The file shows that the provider billed duplicate claims per Medicare guidelines. The claims have both the beneficiary identifier, provider number, date of service, type of service, procedure code, place of service and billed amount. Therefore, we decided that the Plan does not have to pay for the Radiologic examination (71045) and the Computed tomography (74177) provided on April 23, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 27, 2021, to June 25, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive nursing services during the time frame which would be considered skilled services by Medicare.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 27, 2021, to June 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
You asked the Plan to pre-approve hearing aids from an out-of-network provider. You say that the items at issue are necessary and you must get them from this provider. The Plan denied your request. The Plan says the items are not covered from a non-participating provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when the Plan's hearing vendor is utilized. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, items received from an out-of-network vendor are not covered. Therefore, we decided that the Plan does not have to pre-approve hearing aids from an out-of-network provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the enrollee needs SNF care to get her strength back up. The Plan denied your request. The Plan says that the enrollee has not had a change in function to show the need for daily skilled therapy services. The Plan says that the enrollee has no daily skilled nursing needs. The Plan says that the enrollee's needs can be met at a lower level of 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 care. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her baseline. Ongoing strength and endurance training is reasonable. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits.
You asked the Plan to pre-approve additional services. You say that the enrollee has been struggling with increased pain levels limiting mobility. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 additional services. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan.
She has had extensive therapy. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment that can only be performed by a therapist, or by or under the supervision of a therapist. There has been home exercise instruction. The requested services are not part of a maintenance program. The skill of a qualified therapist is not required to establish or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on March 9, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on March 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the foot (73620) rendered by the out-of-network (OON) provider on May 8, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the foot (73620) rendered by the out-of-network (OON) provider on May 8, 2021.