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

We decided that the Plan has to pre-approve the SI joint injection.
You asked the Plan to pre-approve the SI joint injection. You say that you would like reconsideration because this service may give the member some amount of relief and improve their quality of life. The Plan denied your request. The Plan says that there is no documentation of a trial and failure of physical therapy.
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 SI joint injection. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the member has tried and failed chiropractic services and rest. The member is not a candidate for non-steroidal anti-inflammatory drugs. 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 SI joint injection have been met. Therefore, we decided that the Plan has to pre-approve the SI joint injection.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
You asked the Plan to pre-approve the Vertiflex Superion Spacer. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the standard of care for decompression.
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 Vertiflex Superion Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion Spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion Spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for additional units of pulmonary testing (CPT 94727, CPT
94729, and CPT 94375) provided to the enrollee on October 1, 2020.
You asked the Plan to pay for the additional units. You say that this should be paid for. The Plan denied your
request. The Plan says the submitted documentation supports one unit each of CPT 94727, CPT 94729, and
CPT 94375, which were previously approved and paid.
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 is:
CPT 94727:
Gas dilution or washout for determination of lung volumes, and when performed distribution of ventilation and
closing volume
CPT 94729:
Diffusing capacity (eg. Carbon monoxide, membrane)
CPT 93475:
respiratory flow volume loop
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 additional units. Our reviewer says that
the services at issue in this case were not supported by the medical records. Our physician reviewer found there
are no clinical records provided other than the request for the CPET test, and the diagnosis of chest pain. The
plan has already paid for these requested pulmonary studies done on the enrollee individually. There is no
reason provided in the clinical notes that they should be re-billed and paid again as component parts of the
cardiopulmonary exercise test.
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 additional units have not been met. Therefore, we decided that the Plan does not have to pay for additional units of pulmonary testing (CPT 94727, CPT 94729, and CPT 94375) provided to the enrollee on October 1, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81411, 81439, 81479)
provided on July 13, 2020.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that this is supported by the
medical records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
(CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients
with suspected or documented CV disease because panel testing is not specific to a given patient's lipid
abnormality or disease.
We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not
covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular
screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary
cardiovascular screening (81411, 81439, 81479) provided on July 13, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from April 26, 2020, through April 29, 2020.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that the inpatient admission was not medically necessary and does not meet the InterQual 2020 LOC: Adult Acute, General Medical subset criteria.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee was a nursing home resident with a history of Esophageal Ca, s/p G-tube, atrial fibrillation, depression, s/p excision of a brain tumor and BPH who presented to the ER on April 25, 2020 with abdominal pain, vomiting and diarrhea. The enrollee was evaluated with a history and physical exam, laboratory studies and a CT scan of the abdomen and pelvis. He had a WBC elevated to 18.2, Hct 34 and an abnormal urinalysis. CT abdomen and pelvis demonstrated cholelithiasis with a distended gall bladder, large amount of stool in the colon and vertebral compression fractures. He was treated with IV fluids, IV antibiotics and admitted. He was evaluated by General Surgery, had a stool culture for C. dificile and an abdominal ultrasound. He had no evidence of acute cholecystitis. His condition stabilized and improved, and he was discharged back to the nursing facility when considered medically stable on April 29, 2020. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from April 26, 2020, through April 29, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orthovisc.
You asked the Plan to pre-approve Orthovisc. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Orthovisc. Our reviewer says that this request is considered not reasonable and necessary. Our physician reviewer found there is a lack of documentation as to the effect of prior viscosupplementation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Orthovisc.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needs can be provided in a lower level of care setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device. You say that you would like reconsideration because the member urgently needs this device due to their worsening heart failure. The Plan denied your request. The Plan says the notes do not show that the member has been enrolled in a Medicare approved study.
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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found current FDA indications and published clinical data do not provide clinical indications for CardioMEMS in this 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 the CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve a CardioMEMS device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Praluent for the enrollee.
Benefits for this drug 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for epidural hematoma after recent thoracic spinal surgery. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit (99283) provided November 24, 2019.
You asked the Plan to pay for the emergency visit. You say that you have attached the supporting documents of the billed services, so kindly review and process this claim towards payment. The Plan denied your request. The Plan says the claim was submitted past the timely filing limitation.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the emergency visit was not filed until December 15, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency department visit (99283) provided November 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the vertebral corpectomy (63081 and 63082) provided on June 16, 2020.
You asked the Plan to pay for the vertebral corpectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services 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 63081 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment. The CPT Code Manual definition of code 63082 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure). 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 vertebral corpectomy. Our reviewer says that CPT codes 63081 and 63082 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment was performed on June 16,2020. The operative note does not document the removal of at least half of the vertebral body, therefore, 63081 cannot be verified. 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 vertebral corpectomy have not been met. Therefore, we decided that the Plan does not have to pay for the vertebral corpectomy (63081 and 63082) provided on June 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15733) provided on December 14, 2020.
You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap. 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. 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 muscle, myocutaneous, or fasciocutaneous flap. Our reviewer says that CPT code 15733 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided does not include sufficient documentation to validate that a Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) (x 2 ) was performed on December 14, 2020, therefore this service cannot be verified. 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 muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap (15733) provided on December 14, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four (4) additional occupational therapy visits.
You asked the Plan to pre-approve four (4) additional occupational therapy visits. The Plan denied your request. The Plan says four (4) additional occupational therapy visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve four (4) additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You had an occupational therapy (OT) evaluation and refused additional OT and the records do not demonstrate that your functional level needed the unique skills of a professional occupational therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, 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 four (4) additional occupational therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four (4) additional occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99214) provided on October 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that please review the attached documentation which supports payment of CPT 99214. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 the outpatient office visit (99214) provided on October 12, 2020 by an out of network (OON) provider.