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

We decided that the Plan does not have to pay forthe placement of an extension prosthesis (34709) provided on November 28, 2019.You asked the Plan to pay forthe placement of an extension prosthesis. You say that the operative report shows that this was billed correctly.The Plan denied your request. The Plan says this code is not documented in the records.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 34709 is pacement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure).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 placement of an extension prosthesis. Our reviewer says that this code is not supported. Our physician reviewer found the medical records provided do not include documentation that meets the criteria for the code description of 34709.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 placement of anextension prosthesis have not been met.Therefore, we decided that the Plan does not have to pay forthe placement of an extension prosthesis (34709) provided on November 28, 2019.
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-approveIRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for admission to an IRF.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 enrollee does not meet criteria for admission to an IRF. Our physician reviewer found the enrollee is with a past medical history of atrial fibrillation, hypertension and hypothyroidism who presented to the acute hospital on 07/19/2020 after a fall resulting in a right hip fracture. She underwent surgical repair of the fracture and was treated in the hospital for post-operative delirium. She is weak and deconditioned and is working with physical and occupational therapy. She is walking just a few feet with a rolling walker with maximum assistance and is maximum assist for transfers and activities of daily living. She is lethargic and requires maximum encouragement to participate with therapy. She is otherwise medically stable. Based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora tenolysis (26440) performed September 4, 2019.You asked the Plan to pay forthe tenolysis. You say that the services were medically necessary.The Plan denied your request. The Plan says services were not supported in the records.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must reportservices with the appropriate CPT code.In this case, the CPT Code Manual definition of code 26440 is Tenolysis, flexor tendon; palm OR finger, each tendon.We find that CPT code 26440 is not supported in the medical record. Specifically, the operative report does not describe the procedure billed being performed. Based on this information, we decided that Medicare rules for coverage of the tenolysis have not been met.Therefore, we decided that the Plan does not have to pay fora tenolysis (26440) performed September 4, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 above.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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee may require skilled physical therapy and occupational therapy but based on the medical records provided the enrollee does not require treatment in an intensive rehabilitation therapy program.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe emergency room visit provided on February 15, 2020.You asked the Plan to reduce the copayment forthe emergency room visit. You say that the customer service representative gave you the address of an urgent care center. You say you should only be responsible for a $40 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows that you were seen in the emergency department. 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 reduce the copayment for the emergency room visit provided on February 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy lumbar procedure.You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy lumbar procedure (0275T). You say that you need this procedure because you are suffering from severe pain every day.The Plan denied your request. The Plan says Original Medicare pays the services related to your clinical trial.The Plan must follow Medicare rules. Medicare rules say that if you participate in a Medicare-approved study, Original Medicare pays most of the costs for the covered services you receive as part of the study. We looked at the file and Medicare rules. You are enrolled in a clinical research trial. Based on this information, we decided that Medicare rules for coverage of a percutaneous laminotomy/laminectomy lumbar procedure (0275T) have not been met.Therefore, we decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy lumbar procedure.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Sandostatin Lar Depot.
You asked the Plan to pre-approve Sandostatin Lar Depot. You say that the requested Sandostatin Lar Depot is
medically necessary. The Plan denied your request. The Plan says that the requested Sandostatin Lar Depot is
not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 Sandostatin Lar Depot. Our reviewer
says that the requested Sandostatin Lar Depot is medically necessary. Our physician reviewer found the
enrollee is with progressive neuroendocrine cancer with diarrhea. Per NCCN compendia, sandostatin lar depot
is used for treatment of locoregional advanced disease. The enrollee has diarrhea and warrants treatment. The
requested Sandostatin Lar Depot is medically necessary 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 Sandostatin Lar Depot have been met. Therefore, we decided that the Plan has
to pre-approve Sandostatin Lar Depot.
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 a Vertiflex Interspinous Spacer device.
You asked the Plan to pre-approve a Vertiflex Interspinous Spacer device. You say that the requested Vertiflex Interspinous Spacer device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex Interspinous Spacer device is 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 a Vertiflex Interspinous Spacer device. Our reviewer says that the requested Vertiflex Interspinous Spacer device is not medically necessary. Our physician reviewer found the enrollee is with neurogenic intermittent claudication secondary to lumbar spinal stenosis. The requested spacer is experimental. More research is needed to show safety and efficacy. The requested spacer is not medically necessary at this time. 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 Vertiflex Interspinous Spacer device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Interspinous Spacer device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe specialist office visit provided on January 28, 2020.You asked the Plan to reduce the copayment forthe specialist office visit. You say that you were told the provider was in-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.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 $60 copayment per visit for an out-of-network specialist office visit. You have been asked to pay a $60 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows that the provider is out-of-network.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 reduce the copayment forthe specialist office visit provided on January 28, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 17, 2020.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that for conditions that have both an underlying etiology and multiple body system manifestations,the ICD10-CM has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the emergency department visit have not been met. Specifically, the record shows that the claim was billed with only one diagnosis code, I26.90 (Septic pulmonary embolism without acute cor pulmonale). This code has a code first note, which means it is a manifestation code and must be sequenced after an etiology code. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for the services provided on February 17, 2020
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric bed (E0265).
You asked the Plan to pre-approve the total electric bed. You say that the care giver for the enrollee is unable to
manually use a hand crank to raise and lower the bed deck. The Plan denied your request. The Plan says total
electric beds will be denied as not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that this type of bed is not a covered benefit as the
height adjustment is considered a convenience feature. Total electric beds will be denied as not reasonable and
necessary.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the total electric bed have not been met. Therefore, we decided that the Plan does not have to preapprove
a total electric bed (E0265).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the whole body (78816).You asked the Plan to pre-approvea PET CT scan of the whole body. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a PET CT scan of the whole body. Our reviewer says that the services are not medically necessary. Our physician reviewer found the guidelines specify that PET/CT is covered only if there is a confirmed or very strongly suspected diagnosis of malignancy and those criteria are not satisfied based upon the submitted information.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 PET CT scan of the whole body have not been met.Therefore, wedecided that the Plan does not have to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the whole body (78816).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea home medical alert system.You asked the Planto pre-approvethe alert system. You say that you have had recent falls and needed to go to the hospital. You require this system for your health.The Plandenied your request. The Plansaysthis is not a covered services under Medicare.The Plan must follow Medicare rules. Medicare rulessay that telephone alert systems are not covered because they do not serve a diagnostic or therapeutic purpose.Although this system may be appropriate, there is no coverage available for this under Medicare or your Plan.Therefore, we decided that the Plandoes not haveto pre-approvea home medical alert system.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a thyroid uptake scan (78012).
You asked the Plan to pre-approve the thyroid scan. You say that the scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that thyroid testing is covered when 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 thyroid scan. Our reviewer says that the requested scan is not medically necessary. Our physician reviewer found the Thyroid Uptake scan is only medically necessary for the evaluation of thyroid nodules with hyperthyroidism. The basis of thyroid nodule management is the use of ultrasonography (US), thyrotropin (TSH), and a fine needle biopsy, together with clinical findings. Thyroid nodules with serum thyrotropin (TSH) should be measured in the initial evaluation of thyroid nodule for mass, asymmetry, or goiter. A Thyroid Uptake scan should only be performed as the initial imaging study if the serum TSH is subnormal. The records do not support medical necessity in this case. 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 thyroid scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a thyroid uptake scan (78012).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 panel rendered on February 26, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479. The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. 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 Guardant360 panel rendered on February 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 3, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that there was no facility authorization during the date of service.
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 has network providers available who can provide 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 physician services provided on February 3, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillofacial Computed Tomography (CT) scan (70487).
You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the enrollee had a sinus surgery and repeat nasal biopsy done and the results were negative for carcinoma. Repeat imaging at this time is not indicated. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a maxillofacial Computed Tomography (CT) scan (70487).