Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi electric hospital bed (E0260).
You asked the Plan to pre-approve the semi electric hospital bed. You say that the semi-electric hospital bed is necessary. The Plan denied your request. The Plan says the documentation did not show that the enrollee met coverage criteria.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or
2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our 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 semi electric hospital bed. Our reviewer says that the service is not medically necessary. Our reviewer found the record did not note that the enrollee required frequent changes in positioning. 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 semi electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed (E0260).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint.
You asked the Plan to pre-approve the MIS fusion procedure. You say that this procedure is the best option to treat the enrollee's pain. The Plan denied your request. The Plan says the criteria for this procedure have not been met.
The Plan follows Medicare rules. Medicare rules say that MIS fusion of the SI joint is covered for treatment of SI joint pain which persists despite a six-month trial of conservative treatment and which responds to anesthetic injections. 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 MIS fusion procedure. Our reviewer says that the requested procedure is not medically necessary based on LCD criteria. Our physician reviewer found there is no documentation of adequate conservative measures for at least 6 months. Also, the level of pain relief from SI joint injections is not documented. 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 MIS fusion procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve minimally invasive surgical (MIS) fusion of the sacroiliac (SI) joint.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on October 2, 2020.

You asked the Plan to pay for the emergency services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider is ineligible as there was no Medicare ID on file at the time of the services.

The Plan must follow Medicare rules. Medicare rules say that an NPI number is a unique ID for each provider or entity and is required to be used by all healthcare plans for every administrative and financial transaction. 

We looked at the file and Medicare rules. The record shows at the time of the service there was no Medicare ID on file. Based on this information, we decided that Medicare rules for coverage of the emergency services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on October 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (15734) provided February 22, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 15734 is a muscle, myocutaneous, or fasciocutaneous flap of the trunk. We find that CPT code 15734 is not supported in the medical record. Specifically, the operative report provided does not support CPT code billed. Based on this information, we decided that Medicare rules for coverage of
the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (15734) provided February 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.
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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc-One is not approved, as step criteria have not been met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87801, 87150) provided August 8, 2020.
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 the documentation does not support the billed services.
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 codes 87486, 87801, & 87150 are not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (87486, 87801, 87150) provided August 8, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.
You asked the Plan to pre-approve Trulicity. You say that you would like the enrollee to use this medication in addition to diet and exercise to improve his diabetic control and lose weight. The Plan denied your request. The Plan says this drug is not covered under the enrollee's Medicare Part B drug 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 Trulicity.
Benefits for Trulicity may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the revascularization procedure provided on December 22, 2020, billed with code 37228-LT.

You asked the Plan to pay for the revascularization as billed. You say that this service is coded correctly and should be paid. The Plan denied your request. The Plan says that the operative report does not support the use of this code.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our 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 revascularization as billed. Our reviewer says that the documentation does support the billing of this code. Our physician reviewer found CPT code 37228 is defined as revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. The tibioperoneal trunk is considered part of any distal intervention in the posterior tibial or peroneal artery. In this case, the record indicates that the operative procedure included angioplasty of the posterior tibial artery via an open approach. This procedure was performed first prior to the superficial femoral artery treatment. The elements of the coverage criteria are satisfied. 

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 revascularization as billed have been met. Therefore, we decided that the Plan has to pay for the revascularization procedure provided on December 22, 2020, billed with code 37228-LT.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (99153) provided January 26, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 99153 is not supported in the medical record. Specifically, the records shows a Professional Component (PC) / Technical Component (TC) Indicator 3. This code is not separately pat Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (99153) provided January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (70551) provided January 21, 2021.
You asked the Plan to pay for the radiology services. You say that the radiology services were 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 70551 is not supported in the medical record. Specifically, the record shows the enrollee was an inpatient at the time services were performed. The claim was billed with an outpatient place of service. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (70551) provided January 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tube placement provided on March 20, 2021, billed with code 44500.

You asked the Plan to pay for the tube placement as billed. You say that this is correctly coded and payable. The Plan denied your request. The Plan says the use of this code is not supported by the record.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We asked our 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 tube placement as billed. Our reviewer says that the records do not support the use of this code. Our physician reviewer found the record only indicates that a brand name tube was placed. The record does not indicate it was a long intestinal tube. The record is insufficient as it does not state where the tube was placed nor is the subsequent X-ray report available. The elements of the coverage criteria are not satisfied. 

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 tube placement as billed have not been met. Therefore, we decided that the Plan does not have to pay for the tube placement provided on March 20, 2021, billed with code 44500.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798) provided November 25, 2020.
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 the documentation does not support the billed services.
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 codes 87486, 87496, 87498, 87532, 87541, 87581, 87640, & 87798 are not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (87486, 87496, 87498, 87532, 87541, 87581, 87640, 87798) provided November 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
You asked the Plan to provide a therapeutic continuous glucose monitor. You say that the enrollee needs a CGM because of an infection in an index finger. The Plan denied your request. The Plan says the enrollee is not on insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided January 28, 2021.
You asked the Plan to pay for the home health services. You say that the home health services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.
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 the home health services are not supported in the medical record. Specifically, the claim was not billed with a valid place of service. Based on this information, we decided that Medicare rules for coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to pay for home health services provided January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81479) provided November 4, 2020.

You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The
Plan denied your request. The Plan says this was not a covered service.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment testing / panels, except the basic lipid panel, for symptomatic patients for suspected or
documented cardiovascular-respiratory disease.

We looked at the file and Medicare rules. This service is not covered under Medicare. 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 (81479) provided November 4, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria for this device are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH Admission is medically necessary. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.

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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 

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 long term acute care hospital (LTACH) services.
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 IRF care is medically necessary. The Plan denied your request. The Plan says the criteria for this level of care are not 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for above the knee amputation and was treated for congestive heart failure and pulmonary edema.
Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the spinal surgery services provided on September 11, 2020, billed with 63047-59 and 63048.
You asked the Plan to pay for the spinal surgery services as billed. You say that this was correctly billed. The Plan denied your request. The Plan says these services are not separately payable.
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 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 spinal surgery services as billed Our reviewer says that the documentation does not support separate payment for the codes at issue. Our physician reviewer found the record indicates that arthrodesis was performed at three interspaces. Medicare guidelines do not permit the coding of 63047 along with 22630 when performed at the same interspace. The provided records are insufficient to demonstrate that the elements of the coverage criteria are satisfied.
We looked at this physician's review, the file, and Medicare rules. Because code 63047 is not payable, 63048 can also not be paid as it is an add-on code. Based on this information, we decided that Medicare rules for coverage of the spinal surgery services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the spinal surgery services provided on September 11, 2020, billed with 63047-59 and 63048.