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

We decided that the Plan has to pre-approve the mitraclip procedure.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that the provider's offices confirmed there is no enrollment in a clinical trial or study.

The Plan must follow Medicare rules. Medicare rules say that services are covered if 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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you have symptomatic dyspnea and fatigue in the setting of severe mitral insufficiency. You have been evaluated by both a cardiologist and a cardiac surgeon skilled in the procedure. You are felt to be a good candidate for the requested procedure owing to an elevated risk for open surgical valve repair. The health plan contends that you must be enrolled in an ongoing CMS/FDA approved clinical trial to be authorized for this under applicable CMS NCD rules. The rules actually say that you need to be part of post approval follow-up registry, not a randomized clinical trial of the device which has already been FDA approved for this indication. As the manufacturer is required by the FDA order to continue the post approval registry/trial for all patients and submit annually, and the implanting facility participates in this trial, this would meet the CMS criteria.

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve the mitraclip procedure.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 17, 2021.

You asked the Plan to pay for the critical care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service.

The documentation does not include the time spent providing this service; therefore, the billed code cannot be verified. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
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 a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our 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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not show that you are unable to change your own body position or that you require frequent changes in body position. There is no documentation to support that the criteria for coverage of the semi-electric hospital bed are met. The services are 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 semi-electric hospital bed.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight surgical placements of implant bodies: endosteal implants (D6010 x8).
You asked the Plan to pre-approve the endosteal implants. You say that you would like to appeal these services. The Plan denied your request. The Plan says endosteal implants are not covered under your benefit plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve eight
surgical placements of implant bodies: endosteal implants (D6010 x8).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health aide services, 6 hours per week.
You asked the Plan to pre-approve home health aide services. You say that the services are medically necessary. The Plan denied your request. The Plan says you are not homebound. The Plan says that your personal needs are not complex. The Plan also says that your needs can be met with a lower level of care.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 home health aide services. Our
reviewer says that the requested for continued home health aide services is not medically necessary. Our
physician reviewer found the provided documentation is not sufficient to demonstrate that continued home
health aide services are medically reasonable and necessary for the enrollee in this case. The reviewer found
that the need for hands-on personal care of the enrollee or services needed to maintain the enrollee's health or to
facilitate treatment of the enrollee's illness or injury is not supported by the clinical information in the case file.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide services have not been met. Specifically, the file does not
show that the hands-on care is needed to maintain the enrollee's health or facilitate treatment of an illness or
injury. Therefore, we decided that the Plan does not have to pre-approve continued home health aide services, 6
hours per week
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on December 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 services 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 the services provided by an out-of-network provider on December 22, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on
April 23, 2021.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were
billed with an inappropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis
codes that may be used.
We looked at the file and Medicare rules. In this case, the PET scan was not billed with an appropriate
diagnosis code as outlined by Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the
positron emission tomography (PET) scan provided on April 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (97112, 97140) provided to the enrollee on February 4, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

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 the denied codes is: 

CPT 97112: 

Therapeutic procedure, 1 or more areas, each 15 minutes 

CPT 97140:

Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes 

We asked our coding 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 services at issue in this case were not supported by the medical records. Our coding reviewer found the therapy visit states "see flow sheet." The documentation does not include a flow sheet to confirm the services were performed and separate from CPT 97150 which was already reimbursed. Therefore, CPT 97112 and CPT 97140 would not be covered. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services (97112, 97140) provided to the enrollee on February 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoscopic sleeve gastroplasty and inpatient admission for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this procedure is helpful for treatment of the health problem, and the requested hospital stay isn't covered because it's associated with a procedure that isn't covered.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the has morbid obesity and alcoholic cirrhosis. The requested service is for the indication of weight loss. There is insufficient literature that supports the use of the requested service for the enrollee's clinical condition. The requested service is not medically necessary or reasonable, as defined by Medicare rules, for the enrollee's condition. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve an endoscopic sleeve gastroplasty and inpatient admission for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) scan provided on
April 6, 2021.

You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were
billed with an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are
based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis
codes that may be used.

We looked at the file and Medicare rules. In this case, the PET scan was not billed with an appropriate
diagnosis code as outlined by Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the
positron emission tomography (PET) scan provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an electrical stimulation device used for cancer treatment, includes all accessories, any type (E0766) provided March 30, 2021.
You asked the Plan to pre-approve an Electrical stimulation device. You say that you respectfully request reconsideration of the adverse benefit determination. The Plan denied your request. The Plan says that treatment greater than 2 years has not been shown to be warranted and the requested service is not medically necessary.
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 an Electrical stimulation device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Optune is indicated as adjuvant treatment for glioblastoma multiforme after chemotherapy and radiation. Duration of treatment has not been defined especially given the risk of recurrence in the majority of patients. This enrollee has had an unusual response and remains with stable disease. There have been recurrence with cessation of use of Optune for more than several weeks. The service is reasonable and 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 an Electrical stimulation device have been met. Therefore, we decided that the Plan has to pre-approve an electrical stimulation device used for cancer treatment, includes all accessories, any type (E0766) provided March 30, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a medical eye exam (92014) provided on November 4, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for a medical eye exam. You say that the member was seen by a physician for a comprehensive eye exam. You also say that you are asking for a one-time good faith exception of the prior authorization rule. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.

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. The records provided for review do not show that the services at issue were urgent or emergent. 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 a medical eye exam (92014) provided on November 4, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 extractions (41899) and anesthesia (00170).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are dental in nature. The Plan also says that routine dental services are not covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have not been met. Specifically, the services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of the enrollee's teeth or the structures directly supporting the enrollee's teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 2 extractions (41899) and anesthesia (00170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction (92015) provided on February 24, 2021.
You asked the Plan to pay for an eye refraction. You say that your policy states that is covers one eye exam per year. The Plan denied your request. The Plan says this service is only covered following cataract surgery.
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. The Plan covers these services when it is performed as part of a routine eye exam or following cataract surgery. We looked at the file and the Plan's rules. The eye refraction was performed as part of a medical vision exam, and therefore is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of an eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction (92015) provided on February 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 9 skilled nursing home health visits.

You asked the Plan to pre-approve the additional skilled nursing visits. You say that you would like to appeal these services because you have wounds. The Plan denied your request. The Plan says your wounds are considered either superficial or small, and any education/training that you or your caregivers need should have already been provided with the nursing visits you have already had.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 additional skilled nursing visits. Our reviewer says that the documentation does not support that such frequent evaluation by a skilled nurse is medically necessary. Our physician reviewer found your wounds are noted to be small and/or superficial. Our reviewer also found that the Plan's decision to approve only some of the requested visits is reasonable. 

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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 9 skilled nursing home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical need for single power option included with K0856 group 3 power wheelchair.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, you do not have a neurologic disorder with functional deficits. You would meet the criteria for a standard power wheelchair, but the requested group 3 power wheelchair is 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories.