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

 We decided that the Plan does not have to pay for the office visit (99214) provided on August 17, 2021.  You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99214-25 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.  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 office visit. Our reviewer says that CPT code 99214-25 does not meet criteria for billing or reimbursement consideration. Our reviewer found encounters for this date of service support care of Chronic Kidney Disease,  and does not clearly support modifier 25 separately identifiable Evaluation and Management service by the same physician or other qualified healthcare professional.  In this case 2 units is not supported by the documentation, as both visits are not separately identifiable.  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 office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit (99214) provided on August 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (99204, 99343, 99225, 99217) provided
on July 19, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the out-of-network services were not pre-authorized or emergent.
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 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 outpatient services (99204, 99343, 99225, 99217)
provided on July 19, 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 Genvisc.  You asked the Plan to pre-approve Genvisc. The Plan denied your request. The Plan says the enrollee has not failed three months of conservative therapy or failed to respond to aspiration of the knee.  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 Genvisc. Our physician reviewer found that the enrollee has right knee pain due to osteoarthritis. The x-ray report revealed moderate narrowing of the medial joint space of the right knee with subchondral sclerosis in the left tibial plateau. In this case, there is no documentation indicating that the patient has failed at least three months of conservative therapy. In addition, the enrollee has failed to respond to intra-articular corticosteroid injection therapy. The review has determined that the requested injection is not indicated for the enrollee's condition. Therefore, the requested injection is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper partial denture.

You asked the Plan to pre-approve an upper partial denture. You say that you started this dental process believing that this would be covered. The Plan denied your request. The Plan says this service is not covered under your benefits.

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. Therefore, we decided that the Plan does not have to pre-approve an upper partial denture.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you no longer require a stay in a SNF facility.  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 continued services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were independent with functional mobility. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pre-approve Bioimpedance Spectroscopy.  You asked the Plan to pre-approve the Bioimpedance Spectroscopy. You say that you would like reconsideration because the requested service is medically necessary. The Plan denied your request. The Plan says that the requested service is considered experimental.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Bioimpedance Spectroscopy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found CMS recognizes cpt 93702 as a billable procedure.  The requesting physician has provided ample literature references advocating the use of the technology in order to assess the likelihood of lymphedema and the use of the data obtained with the test to institute the appropriate type of therapy to minimize the development of lymphedema.  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 Bioimpedance Spectroscopy have been met. Therefore, we decided that the Plan has to pre-approve Bioimpedance Spectroscopy.   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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme.

You asked the Plan to pre-approve Feraheme. You say that you would like reconsideration because the requested drug is medically necessary. The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Feraheme. Our reviewer says that the Plan requires a trial of drug(s) Infed (iron dextran) and Venofer (iron sucrose) before they will approve the requested drug, Feraheme. Based on the medical records provided the member has not tried and failed the required drugs. Our physician reviewer found based on the medical records provided there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects for the member. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have to pre-approve Feraheme.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Hydrocodone/acetaminophen for the enrollee.  You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to those covered under the medical benefit.  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 Hydrocodone/acetaminophen for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an unspecified implant procedure, by report (D6199)
and sinus augmentation via a vertical approach (D7952).
You asked the Plan to pre-approve an unspecified implant procedure and sinus augmentation. You say that you
would like these services covered. The Plan denied your request. The Plan says these services are not covered
under your benefits.
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. Therefore, we decided that the Plan does not have to pre-approve an
unspecified implant procedure, by report (D6199) and sinus augmentation via a vertical approach (D7952).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0239U) provided July 30, 2021.

You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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. 

We find that CPT code 0239U is not supported in the medical record. Specifically, a comprehensive genetic panel should be reported using CPT code 81479. 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 lab services (0239U) provided July 30, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve physical therapy. You say that you need peripheral decompression therapy in addition to your current physical therapy treatment with a Plan physical therapist. You say this therapy has helped you to improve dorsiflexion and control of your left leg. The Plan denied your request. The Plan says medically necessary care is accessible and available for the enrollee within the Plan's network of 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 requested provider in this case is not a network provider with the Plan. The Plan has network providers

available who can provide the 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 physical therapy to be provided by the requested out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on June 8, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were
billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 11. However, the records do not show that the specimen was collected in an office setting. This
means that the claim was billed with the incorrect POS code.
Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endosteal implant (D6010) for tooth #31 and #32 to
be provided by a participating provider.

You asked the Plan to pre-approve an endosteal implant. You say that you would like the Plan to pay for these
implants. The Plan denied your request. The Plan says the requested dental work is not 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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
endosteal implant (D6010) for tooth #31 and #32 to be provided by a participating provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac gel.

You asked the Plan to pre-approve Diclofenac gel. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Diclofenac gel.

Benefits for Diclofenac gel 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the radiologic examination of the hips,
bilateral, with pelvis when performed; minimum of 5 views (73523) provided on September 22, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the services provided.
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 $10 per
day for Medicare-covered x-rays.
You have been asked to pay $10 for the Medicare-covered x-rays provided. 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 the radiologic examination of the hips, bilateral, with pelvis when performed;
minimum of 5 views (73523) provided on September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (CPT code 31295, 31296 x2, 31297 x2), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the request for balloon sinuplasty is not medically reasonable and necessary. The enrollee reported symptoms such as nasal congestion and facial pressure; however, endoscopic examination and imaging results showed no clear objective evidence of chronic rhinosinusitis (CRS) such as purulence. Polypoid thickening is an intermediate finding between absence of polyps and frank polyposis (Banerji et al., Am J Rhinol 2017), and at the visit dated January 28, 2022, four (4) days after the computed tomography (CT), the nasal exam demonstrated no polyps. The definition of CRS, according to the 2015 American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline on adult sinusitis, requires both symptoms and documented evidence of inflammation such as polyps, edema, or purulent mucus. Moreover, the expert panel on the 2018 AAO-HNSF clinical consensus statement on balloon sinus dilation achieved consensus on statement #2 ("Balloon dilation is not appropriate for patients with sinonasal symptoms and a CT that does not show evidence of sinonasal disease"). The patient's CT results showed no overt evidence of CRS. Given the available clinical documentation, the use of balloon sinuplasty does not appear to be indicated for the enrollee's symptoms. In summary, balloon sinuplasty is not medically reasonable and necessary to manage 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa (CPT code 31295, 31296 x2, 31297 x2), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion.  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available.  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 requested provider in this case is not a network provider with the Plan. 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 items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral for a second opinion.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for occupational therapy visits provided from August 2, 2021. to August 4, 2021  You asked the Plan to waive the copayment for the occupational therapy visits. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 a $40 copayment for Outpatient rehabilitation services.    You have been asked to pay a $80 copayment for two occupational therapy visits rendered in an outpatient hospital. Occupational therapy visits fall within the Outpatient rehabilitation services benefit category. 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 occupational therapy visits provided from August 2, 2021. to August 4, 2021