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

We decided that the Plan does not have to pre-approve injection procedure for SI joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.
You asked the Plan to pre-approve the injection. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our physician reviewer found criteria for repeat SI injection not met. There is no documentation of any degree of functional improvement or any change in physical exam after previous injection 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 the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection procedure for SI joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed (CPT code 27096), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided on February 6, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis code is not supported.

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 I21.A1. 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 services. Our reviewer says that the use of diagnosis code I21.A1 is not supported by the records provided. Our physician reviewer found that the enrollee is a 67-year-old male who was admitted to the hospital with shortness of breath and chest pain, found to have atrial flutter. Troponins were 0.641, 0588, 0.630. Diagnosis code, I21.A1 (acute myocardial infarction type II) was billed. Based on the provided documentation and the clinical course, there was insufficient evidence to support myocardial infarction in this case. The elevated troponins were likely related to stress to the heart from atrial flutter, which was later controlled. 

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 services provided on February 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and the accessories (CPT code(s): E2311, E2361, E1007, E1028, E0955, E1028, E2208, E0990 and E2603), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the enrollee does not have medical need for multiple power options included with K0842 group 2 power wheelchair with multiple power options. You state the enrollee does not have a qualifying diagnosis causing mobility limitation for K0861 group 3 power wheelchair listed on the quote submitted. The Plan states that as the base code for the requested wheelchair is not reasonable and necessary, none of the requested accessories can be approved.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 DME. Our physician reviewer found based on the medical records provided the enrollee does not meet LCD criteria for a group 3 power wheelchair as the mobility limitation is due to chronic obstructive pulmonary disease, congestive heart failure, lumbar spinal fusion and morbid obesity and not due to a neurological condition, myopathy, or congenital skeletal deformity. 

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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds (CPT code K0861) and the accessories (CPT code(s): E2311, E2361, E1007, E1028, E0955, E1028, E2208, E0990 and E2603), for the enrollee.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve reduction in breast size (reduction mammoplasty) of the opposite breast (right breast), for the enrollee.

You asked the Plan to pre-approve the surgery. You say that the service is necessary. The Plan denied your request. The Plan says that the enrollee will undergo left breast lumpectomy with reconstruction. You state the enrollee is undergoing localized lump removal (lumpectomy) and not whole breast removal (mastectomy). The Plan states that according to Medicare rules the requested service is covered following breast cancer surgery to correct asymmetry of the breasts. The Plan states the requested service of the breast reduction of the left breast should be done following cancer surgery and not simultaneously as has been requested in the enrollee's case.

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 surgery. Our physician reviewer found the record indicates that the enrollee is scheduled to have a lumpectomy and sentinel lymph node biopsy of the left beast that has been approved. The record indicates that the right breast is larger than the left before surgery. The requested service is to reduce the size of the normal breast to create symmetry with the breast operated on for cancer. The elements of the coverage criteria are satisfied. The requested service is recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have been met. Therefore, we decided that the Plan has to pre-approve reduction in breast size (reduction mammoplasty) of the opposite breast (right breast), for the enrollee.

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 initial hospital care (99223) on January 30, 2021, and subsequent hospital care (99233) on January 31, 2021.

You asked the Plan to pay for initial hospital care and subsequent hospital care. You say that these codes are supported. The Plan denied your request. The Plan says these codes are not documented.

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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. The definition of 99233 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

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 initial hospital care and subsequent hospital care. Our reviewer says that these codes are not supported. Our reviewer found on both dates of service, the submitted medical records only document medical decision making of straightforward complexity. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of initial hospital care and subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care (99223) on January 30, 2021, and subsequent hospital care (99233) on January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics. 
 
You asked the Plan to pre-approve foot orthotics. You say that orthotics is medically necessary. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require
specialized equipment or staff for his therapy.

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 physician reviewer found
that you were admitted to the acute care hospital for dizziness and falls. Your medical problems are stable. The
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you do not have enough strength to stand and you are a fall risk. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 17, 2021, to March 9, 2021.

You asked the Plan to pay for the SNF care provided from February 17, 2021, to March 9, 2021. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require skilled services on the dates of service in this case.

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 SNF care provided from February 17, 2021, to March 9, 2021. 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 SNF care provided from February 17, 2021, to March 9, 2021, have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 17, 2021, to March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the implantation of the sacral nerve stimulator for incontinence.

You asked the Plan to pre-approve implantation of the sacral nerve stimulator for incontinence.. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a sacral nerve stimulator for incontinence is subject to the criteria listed 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 implantation of the sacral nerve stimulator for incontinence. Our reviewer says that the requested item is not medically necessary and reasonable. Our physician reviewer found in this case, conservative therapy has not been exhausted to manage the member's symptoms, insufficient documentation on appeals for behavioral or surgical therapy. The review indicates that the enrollee did not meet the specified Medicare criteria for the sacral nerve stimulator. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of the sacral nerve stimulator for incontinence. have not been met. Therefore, we decided that the Plan does not have to pre-approve the implantation of the sacral nerve stimulator for incontinence.
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 care is medically necessary. The
Plan denied your request. The Plan says continued medically necessary care can be provided in the current
acute care hospital.

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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the scleral lenses.

You asked the Plan to pre-approve the lenses. You say that the doctor thinks you might benefit from a scleral lens. The Plan denied your request. The Plan says specialty contact lenses are not approved.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the lenses have not been met. Specialty lenses and contacts are not covered. Therefore, we decided that the Plan does not have to pre-approve the scleral lenses.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has back pain due to sacroilitis, lumbar post-laminectomy syndrome, and lumbar radiculopathy. There is no documentation on physical exam of tenderness on the SI joint and no mention of SI joint provocative testing being completed with positive findings. The SI joint injection is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac (SI) joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on February 1, 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 supplies are not covered.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 frequently adjust the insulin treatment regimen based on blood glucose testing results. 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 continuous glucose monitor (CGM) supplies rendered on February 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat Zilretta injection. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee had good results from a 
prior Zilretta injection. She also had a Euflexxa injection three weeks prior and should wait for that to be 
ineffective prior to doing another treatment. The records do not support that a repeat Zilretta injection is safe 
and effective and reasonable or medically necessary for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a repeat Zilretta injection.