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

We decided that the Plan does not have to pre-approve placement of a Sprint peripheral nerve stimulation 
(PNS) device. 
 
You asked the Plan to pre-approve the Sprint PNS procedure. You say that it is felt that this treatment would be 
beneficial and reduce the enrollee's pain. The Plan denied your request. The Plan says the current peer-
reviewed data does not support peripheral nerve field stimulation for any 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 the Sprint PNS procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found this 73-year-old patient has right back pain and right leg pain. He takes Lyrica and 
Ibuprofen for pain. He has had Epidural steroid injection and Trigger Point Injections. His imaging shows 
multi-level bulging discs, and an annular fissure. However, the requested treatment is experimental/ 
investigational for this patient's pain. Therefore, the request is deemed 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 Sprint PNS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of a Sprint peripheral nerve stimulation (PNS) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 an Intracept procedure. 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. More research is needed to show 
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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the speech therapy services rendered on June 22, 2020. 
 
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 procedure code 92526 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. 
 
In this case, the CPT Code Manual definition of code 92526 is treatment of swallowing dysfunction and/or oral 
function for feeding. 
 
We find that CPT code 92526 is not supported in the medical record. Specifically, the records show that the 
services were performed in the home setting and there is a more appropriate code for these services. 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 speech therapy services rendered on June 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and 
an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or 
occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the 
intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87496, 97498, 97532, 87541, 87640, 
87798) provided on March 9, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were necessary and should be 
covered. The Plan denied your request. The Plan says screening panels and testing with no relation to a medical 
diagnosis or disease for the health of the enrollee are not a covered benefit. 
 
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 pay for the lab services. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records provided do not clearly show that the enrollee had a more complex or unusual case 
of upper respiratory illness to justify so many organisms to be tested. Rhinovirus (common cold) was noted as 
resulted from the broad panel of test results. There was no history or physical findings to justify the other 
organisms being tested. Therefore, the lab services will be considered not medically necessary as ordered. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for the laboratory services (87496, 97498, 97532, 87541, 87640, 87798) provided on March 9, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intravenous (IV) tubing extension set and infection 
control supplies rendered on April 30, 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 procedure codes S1015 and S8301 are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. Billed procedure codes S1015 (IV tubing extension set) and S8301 
(infection control supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we 
decided that the Plan does not have to pay for the intravenous (IV) tubing extension set and infection control 
supplies rendered on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214), the destruction of benign lesions 
other than skin tags (17110), and the additional supplies, materials, and clinical staff time over and above those 
usually included in an office visit or other non-facility service(s) when performed during a Public Health 
Emergency (99072) rendered by the out-of-network (OON) provider on March 9, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the office visit (99214), the destruction of benign lesions other than skin tags 
(17110), and the additional supplies, materials, and clinical staff time over and above those usually included in 
an office visit or other non-facility service(s) when performed during a Public Health Emergency (99072) 
rendered by the out-of-network (OON) provider on March 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81551) provided May 23, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare covers SelectMDx in males with 
previous negative prostate biopsy who are being considered for repeat biopsy. 
 
We looked at the file and Medicare rules. The record does not show a previous negative prostate biopsy. 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 (81551) provided May 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G1-V7 provided from January 4, 2021 to January 30, 2021.
You asked the Plan to pay for codes J0604-AX and 90999-G1-V7. 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. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code J0604 is Cinacalcet, oral, 1 mg, (for esrd on dialysis). The definition of code 90999 is Unlisted dialysis procedure, inpatient or outpatient. We find that CPT codes J0604-AX and 90999-G1-V7 are not supported in the medical record. Specifically, J0604 was billed with a modifier no longer payable by Medicare as of January 1, 2021. As a result, the associated dialysis services associated with this drug administration will also be denied. Based on this information, we decided that Medicare rules for coverage of codes J0604-AX and 90999-G1-V7 have not been met. Therefore, we decided that the Plan does not have to pay for Cinacalcet coded as J0604-AX and unlisted dialysis procedure coded as 90999-G1-V7 provided from January 4, 2021 to January 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that these services are available in 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 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 a spinal cord stimulator trial to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occupational therapy evaluation.
You asked the Plan to pre-approve an occupational therapy evaluation. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 an occupational therapy evaluation. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of your condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition at this time beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your 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 an occupational therapy evaluation have not been met. Therefore, we decided that the Plan does not have to pre-approve an occupational therapy evaluation.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (80307, G0480, 82542, 84228) rendered by the out-of-network (OON) provider on May 25, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (80307, G0480, 82542, 84228) rendered by the out-of-network (OON) provider on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 21, 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 are not covered.
The Plan must follow Medicare rules. The rules say that genetic testing procedures submitted under CPT code 81455 are denied as not medically necessary. We looked at the file and Medicare rules. The services are billed under code 81455. 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 laboratory services rendered on May 21, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on June 22, 2020.
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 procedure code 97530 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.
In this case, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.
We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the
services were rendered in the home setting and there is a more appropriate code for these services. 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 occupational therapy services rendered on June 22, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 31, 2020, to September 12, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the documentation does not support the swallowing disorders coded.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 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 SNF services. Our reviewer found that the enrollee was hospitalized with anemia and generalized muscle weakness. Skilled Nursing Facility services were then rendered. The enrollee was on a regular diet, pureed consistency, thin liquids because of dysphagia. Treatment included swallowing dysfunction. The available clinical documentation does not support the inclusion of malnutrition/risk of malnutrition as an active diagnosis for the SNF stay at issue. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from August 31, 2020, to September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you have seen many providers without help and would like to try the OON provider. The Plan denied your request. The Plan says they have multiple in-network providers available to treat your condition.
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 office visit to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pelvic floor therapy (97110) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve pelvic floor therapy. You say that you need specialized care only available from the requested provider. The Plan denied your request. The Plan says this is available in-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 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 pelvic floor therapy. Our reviewer says that the records do not show that it is medically necessary for you to receive services from the requested provider rather than an in-network provider. Our physician reviewer found the documentation provided show that there are two locations within the network that can provide pelvic therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pelvic floor therapy 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 pelvic floor therapy. Therefore, we decided that the Plan does not have to pre-approve pelvic floor therapy (97110) to be provided by an out-of-network (OON) provider.