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

We decided that the Plan does not have to pay for a neurostimulator placement (64555, L8679) provided December 11, 2020.

You asked the Plan to pay for the neurostimulator placement. You say that the services were medically necessary. 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. 

We find that CPT code 64555, & L8679 is not supported in the medical record. Specifically, Code L8679 was not billed with an appropriate place of service and the 25 modifier was applied incorrectly to CPT code 64555. Based on this information, we decided that Medicare rules for coverage of the neurostimulator placement have not been met. Therefore, we decided that the Plan does not have to pay for a neurostimulator placement (64555, L8679) provided December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (83305) provided on January 27, 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 the out-of-network services were not pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 lab services (83305) provided on January 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genetic testing services represented by common
procedural terminology (CPT) codes 88360, 88342, 88341, 88381, and 81455.

You asked the Plan to pre-approve the genetic testing services. You say that you need this requested testing
done for your cancer related issues. You say that you have very little time because the testing could lead to
treatment that would extend your life. The Plan denied your request. The Plan says the documentation provided
did not support the need for these specific genetic tests.

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 genetic testing services. Our
reviewer says that the requested genetic testing services are not considered medically reasonable and necessary
in this case. Our physician reviewer found there is insufficient evidence to support the use of the MI Profile test
to aid oncologists in personalizing cancer therapies and treatment decisions from among more than 60 FDAapproved
therapies.

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 genetic testing services have not been met. Therefore, we decided that the
Plan does not have to pre-approve genetic testing services represented by common procedural terminology
(CPT) codes 88360, 88342, 88341, 88381, and 81455.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (81479) provided December 17, 2020.

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. 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.

We find that CPT code 81479 is not supported in the medical record. Specifically based on the records and plan
outreach to the provider, it was determined that the services at issue were not ordered by the the physician.
Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been
met. Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided December
17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis, knee orthosis and suspension sleeve provided on October 16, 2020.

You asked the Plan to pay for lumbar-sacral orthosis (L0648), knee orthosis (L1833LT) and suspension sleeve (L2397LT). You say that the Plan should pay this claim. The Plan denied your request. The Plan says they are unable to discover any evidence of an established relationship between the member and the ordering physician and the supplier is not certified by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Medicare will only cover your DMEPOS if your doctors and suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren't enrolled, Medicare won't pay the claims submitted by them. This provider is ineligible to receive payment. Based on this information, we decided that Medicare rules for coverage of lumbar-sacral orthosis (L0648), knee orthosis (L1833LT) and suspension sleeve (L2397LT) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis, knee orthosis and suspension sleeve provided on October 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of a spinal cord stimulator for the back.

You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee has tried and failed
numerous conservative measures and is a candidate for this procedure. The Plan denied your request. The Plan
says the denial of authorization for this service is correct, because the enrollee is not being treated for any
covered condition for a spinal cord stimulator.

The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators are only covered for certain
indications.

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 spinal cord stimulator. Our reviewer
says that the enrollee does not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer
found the enrollee has chronic lower back pain. She is taking over-the-counter analgesics and tizanidine for the
pain. She had an epidural steroid injection which produced 50% pain relief. She has had physical therapy and
chiropractic treatment in the past. She has not had spinal surgery or any other evidence-based indication for a
spinal cord 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan
does not have to pre-approve implantation of a spinal cord stimulator for the back.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Watchman device implant procedure.You asked the Plan to pre-approve the requested services. You say that continuing oral anticoagulation long term, in the setting of labile INR's has the potential to result in stroke or severe bleeding.The Plan denied your request. The Plan says LAAC is only covered as a second line therapy to oral anticoagulants.The Plan follows Medicare rules. Medicare rules say that a Left Atrial Appendage Closure is only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has an elevated CHA2DS2VASc score and paroxysmal atrial fibrillation. She is maintained on warfarin therapy.There is no documentation of a formal shared decision-making interaction with an independent non-interventional physician found in the record. It is only mentioned by the implanting physician in there quest. The enrollee has some evidence of labile INRs and a somewhat elevated HASBLED score of 3.Although Eliquis has not been affordable on current plan, there is no report of a prescription of Xarelto or Pradaxaas possible formulary alternatives being investigated for alternative anticoagulation. As the enrollee does not meet the coverage criteria, the requested service is considered not 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 the requested services have not been met.Therefore, we decided that the Plan does not have to pre-approve a Watchman device implant procedure.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to provide continued skilled nursing facility (SNF) services after June 16, 2021.

You asked the Plan to provide SNF care. You say that the enrollee needs continued SNF services. The Plan denied your request. The Plan says that the enrollee does not require daily skilled services on an inpatient basis at the SNF level.

The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. 

We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before June 16, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to provide continued skilled nursing facility (SNF) services after June 16, 2021.

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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).

You asked the Plan to pre-approve an MRI. You say that this is medically necessary.The Plan denied your request. The Plan says that the enrollee has not had conservative therapy and does not have a neurological deficit.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 an MRI. Our reviewer says that the requested MRI is medically necessary. Our physician reviewer found the enrollee has new onset left foot weakness that impairs her ability to climb stairs and walk. The enrollee had an MRI in 2018 that demonstrated degenerative changes.

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 MRI have been met.Therefore, we decided that the Plan has to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).

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: Favorable

We decided that the Plan has to pre-approve an implantable loop recorder.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that the enrollee has not had a syncopal event or a cryptogenic stroke.

The Plan follows Medicare rules. Medicare rules say that electrocardiographic services are only covered under certain medical indications.

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 requested services. Our physician reviewer found that the enrollee has a history of ischemic heart disease and atrial fibrillation (AF). He failed cardioversion with recurrence of symptomatic AF and did not tolerate Amiodarone secondary to fatigue. He was referred for and underwent AF ablation. The plan post-AF ablation is to continue Amiodarone therapy for at least 6 weeks and perhaps longer if he has recurrences of AF. As he has had side effects from Amiodarone one would try to avoid long-term therapy if at all possible. Assessment of recurrence of AF post ablation is important in medical decision making, and longer-term monitoring with an implantable recorder is a medically reasonable option in this situation. This is especially important since post ablative AF tends to be more often asymptomatic unlike pre-ablation disease. The loop recorder detection rates of asymptomatic episodes generally tend to be better. This also meets the CMS criteria for transtelephonic EKG monitoring as well as medical reasonableness and necessity based on the clinical plans for this 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 the requested services have been met. Therefore, we decided that the Plan has to pre-approve an implantable loop recorder.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on November 30, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment panels.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, genetic tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular screening panel testing provided on November 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third level of paravertebral facet joint injections (64492).
You asked the Plan to pre-approve a third level of paravertebral facet joint injections. You say that this is medically necessary. The Plan denied your request. The Plan says a third level is not supported.
The Plan follows Medicare rules. Medicare rules say that one to two levels of facet joint procedures, either unilateral or bilateral, are allowed per session per spine region. 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 a third level of paravertebral facet joint injections. Our reviewer says that the requested injections do not meet the requirements for coverage. Our physician reviewer found only 2 levels bilaterally are deemed medically reasonable and 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 a third level of paravertebral facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve a third level of paravertebral facet joint injections (64492).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator (E0466).

You asked the Plan to pre-approve a home ventilator. You say that this should be covered.The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 a home ventilator. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the records show that you have chronic respiratory failure secondary to chronic obstructive lung disease. The record indicates that you are using a ventilator in Bilevel Positive Airway Pressure (BiPAP)-Average Volume Assured Pressure Support (AVAPS) mode. You are using the device l4 hours or more less than 25% of the time. A BiPAP-AVAPS machine could be utilized.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approve a home ventilator (E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a biopsy provided by a participating
provider on January 20, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you went for a biopsy. You
say that this should only by $150. You say that you made sure that this provider was in-network. The Plan
denied your request. The Plan says the correct copayment has been applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250
copayment for outpatient surgery/in-network/outpatient hospital.

You have been asked to pay a $250 copayment for an outpatient surgery. There is a $250 copayment for
surgery provided at an outpatient hospital facility. An outpatient surgery falls within the outpatient surgery/innetwork/
outpatient hospital benefit category. This means that you have been asked to pay the correct amount
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a biopsy
provided by a participating provider on January 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dermasweep with Epifusion.You asked the Plan to pre-approve Dermasweep with Epifusion. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that Dermasweep with Epifusion is only covered for certain indications.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 Dermasweep with Epifusion. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has cystic acne, hyperpigmentation and skin irregularities. The medical records submitted do not indicate that here is a functional impairment or that the deformities are so severely disfiguring as to merit consideration of corrective surgery. The elements of the coverage rule are not satisfied. Therefore, the enrollee does not meet criteria for the requested 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 Dermasweep with Epifusion have not been met.Therefore, we decided that the Plan does not have to pre-approve Dermasweep with Epifusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.You asked the Plan to pre-approve seat lift mechanism. You say that it is hard for you to get out of a chair.The Plan denied your request. The Plan says the denial of authorization for this device is correct, because there is no documentation showing that you are completely incapable of standing up from a regular armchair on your own.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are 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 seat lift mechanism. Our reviewer says that you do not meet the Medicare criteria for a seat lift mechanism. Our physician reviewer found you have a neuromuscular disease. The records do not indicate that a seat lift mechanism is included in your treating provider's course of treatment. The records do not clearly document that a seat lift is likely to effect improvement in your condition or slow or stop deterioration in your condition. The records do not document that you are completely incapable of standing from a chair in the home.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.