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

We decided that the Plan does not have to pre-approve GAINSWave shock wave therapy for the enrollee.
You asked the Plan to pre-approve the therapy. You say that the urologist has exhausted all modalities of treatment. The Plan denied your request. The Plan says this is experimental, investigational, and unproven.
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 therapy. Our reviewer says that the requested therapy is not considered medically reasonable and necessary in this case. Our physician reviewer found this therapy is experimental for the treatment of erectile dysfunction. GAINSWave shock wave therapy is not currently FDA approved for the treatment of erectile dysfunction. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve GAINSWave shock wave therapy for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the brow lift procedure you had on September 12, 2019.
You asked the Plan to pay for the procedure. You say that this was necessary. The Plan denied your request. The Plan says this was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that upper eyelid and brow procedures are covered for the above 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 pay for the procedure. Our reviewer says that the requested brow lift procedure was not medically reasonable and necessary. Our physician reviewer found that Medicare criteria were not met for upper eyelid blepharoplasty based the history and physical documentation. According to LCD L34028, "interference with vision or visual field" should justify functional surgery. The "records must include patient complaints" such as "interference with vision or visual field, related to activities such as, difficulty reading due to upper eyelid drooping, looking through the eyelashes, seeing the upper eyelid skin, or brow fatigue". These conditions are not satisfied as there are no functional visual complaints. Visual fields are absent from the record. There should be objective visual field testing demonstrating the requirement of 12-degree or 30% improvement when the eyelids are taped. 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 not been met. Therefore, we decided that the Plan does not have to pay for the brow lift procedure you had on September 12, 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-approve IRF care. You say that you think that you need rehab in the hospital setting due to your condition. The Plan denied your request. The Plan says you are medically stable and are likely to make measurable gains without three hours of daily therapy. This request exceeds your medical need.
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 the enrollee recently suffered a fall which injured her knee. X-rays showed no acute injury but showed chronic joint disease. Records do not indicate that there are significant, or complex medical/nursing issues that require regular physician supervision in the hospital setting. In this case, the member requires mostly standby assist for functional transfers and ADL's and a less intensive, longer duration of therapy or home health services, can allow for measurable gains to be attained, within a predicted and reasonable period. 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea computed tomography (CT) scan of the chest (71260), CT scan of the abdomen and pelvis (74177), and CT scan of the neck (70491).You asked the Plan to pre-approvea CT scan of the chest, CT scan of the abdomen and pelvis, and CT scan of the neck. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, 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 a CT scan of the chest, CT scan of the abdomen and pelvis, and CT scan of the neck. Our reviewer says thatthe services are medically necessary. Our physician reviewer found there is detailed discussion in the records concerning the possibility of low grade lymphoma based upon the pathology of the sampled right thyroid nodule. As such CT of the neck, chest, abdomen and pelvis would allow for screening this enrollee with abnormal pathology within a thyroid nodule possibly consistent with same.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of a CT scan of the chest, CT scan of the abdomen and pelvis, and CT scan of the neck have been met.Therefore, we decided that the Plan has to pre-approvea computed tomography (CT) scan of the chest (71260), CT scan of the abdomenand pelvis (74177), and CT scan of the neck (70491).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 hasto 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 the Plan does not have to waive the copayment for arthrocentesis and does not have to waive the coinsurance for X-rays and a Medicare Part B drug provided on November 25, 2019. You asked the Plan to waive the copayment for arthrocentesis and to waive the coinsurance for X-rays and a Medicare Part B drug. You say that you were not informed that you would not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for services obtained by a specialist. Your contract with the Plan also clearly says that you must pay 10% coinsurance for each X-ray. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received arthrocentesis on November 25, 2019. Therefore, you are responsible to pay the $35 copayment. You received X-rays on November 25, 2019. The total allowed amount is $114.34 and 10% of that is $11.43. You received a Medicare Part B drug on November 25, 2019. The total allowed amount is $1,183.19 and 10% of that is $236.64. The total amount you owe is: $283.07. You have been asked to pay the total amount of $283.07 for arthrocentesis, X-rays and a Medicare Part B drug. Arthrocentesis falls within the physician/practitioner services, including doctor's office visits benefit category. X-rays falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 arthrocentesis and does not have to waive the coinsurance for X-rays and a Medicare Part B drug provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat epidural steroid injections (ESIs) and epidurography.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that ESIs are covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have chronic back pain and have received multiple pain injections. Multiple pain injections in a single day is not the standard of care and is not covered by Medicare. There is no documentation of greater than 50 percent pain reduction and improved activities of daily living after the previous injections. Epidurograms are integral to the epidural steroid injection procedure and separate coding represents bundling. The documentation does not support that the services are 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 repeat epidural steroid injections (ESIs) and epidurography.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the SI joint for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says sacroiliac joint RFA is currently not a standard of care and accepted medical practice. 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 this is medically necessary. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the lateral sacral branches is considered experimental and investigational because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is considered not medically reasonable or 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 this injection have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the SI joint for the enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Luspatercept for the enrollee.
You asked the Plan to pre-approve Luspatercept. You say that this is medically necessary. The Plan denied your request. The Plan says that that they cannot approve a drug that has not received FDA approval for treatment.
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 Luspatercept. Our reviewer says that Luspatercept is medically reasonable and necessary for the enrollee in this case. Luspatercept is supported by major drug compenida for off-label use for the treatment of anemia due to lower-risk myelodysplastic syndromes (MDS) with ring sideroblasts. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Luspatercept. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Luspatercept have been met. Therefore, we decided that the Plan has to pre-approve Luspatercept for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937) Intraoperative Neurophysiology (95940) provided July 22, 2019. You asked the Plan to pay for the intraoperative neurophysiological monitoring. You say that intraoperative monitoring with real time physician oversight provides a vital service to the surgeons to protect their patients from potential positional and operative injury. The Plan denied your request. The Plan says the medical records provided do not support billing the codes. 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 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 intraoperative neurophysiological monitoring. Our reviewer says that the documentation does not support that Medicare coverage criteria has been met. Our physician reviewer found the medical records provided do not include documentation of Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method being performed. The medical records document that Train of Four Testing was performed. Train of Four testing does not meet the description associated with CPT code 95937. There is no CPT code that specifically describes Train of Four Testing, therefore, it is inappropriate to use CPT code 95937 to represent the service. The medical records provided does not include enough documentation to corroborate that continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) was provided, therefore this service cannot be considered for reimbursement. 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 intraoperative neurophysiological monitoring have not been met. Therefore, we decided that the Plan does not have to pay for neuromuscular junction testing (95937) Intraoperative Neurophysiology (95940) provided July 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 60 home health nursing visits. You asked the Plan to pre-approve 60 home health nursing visits. You say that the requested 60 home health nursing visits are medically necessary. The Plan denied your request. The Plan says they were unable to make a determination within the allotted time frame. 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 60 home health nursing visits. Our reviewer says that the requested 60 home health nursing visits are not medically necessary. Our physician reviewer found the enrollee is diagnosed with encounter for orthopedic aftercare following surgical thumb amputation and unspecified wound, right lower leg, subsequent encounter. The enrollee's physician stats that the enrollee had multiple surgical failures and has signs of healing for the first time in months. There is evidence of wound optimization. The first stage of reconstruction was 1/29/20 with a skin graft. The physician feels the need for wound care is ongoing. 1/6/20 wound assessment left thumb no change in status. 1.4 x 1.2 x 0.3 cm closed surgical wound. There is epitheliazation, no undermining, no tunneling, no pain no infection.
The documentation does not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee's chronic wounds. The wounds appear chronic without evidence of infection. The enrollee has had extensive prior wound care. There has been nursing instruction on cleansing and wrapping of the wounds. The enrollee's wound care needs are not complex and do not require the ongoing skills of a professional nurse therefore the request for 60 home health nursing visits 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 60 home health nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 60 home health nursing visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CT scan of the chest with contrast.
You asked the Plan to pre-approve the CT scan. You say that the enrollee should be given this imaging due to her symptoms. The Plan denied your request. The Plan says the enrollee's condition does not warrant CT imaging at this time.
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 requested imaging is not considered reasonable and necessary at this time. Our physician reviewer found the enrollee is a 79 year old female with a history of a less than 6mm lung nodule on CT scan obtained 2-5 years ago. She has been having chest pain and shortness of breath. She has no other known risk factors for lung disease. There is no specific clinical rationale for the requested CT scan. If a solid lung nodule is smaller than 6 mm, no follow-up is necessary unless the patient is considered to be high risk, in which case a follow-up CT scan is recommended at 12 months. This CT scan 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest with contrast.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from March 3, 2018, to March 9, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there was insufficient clinical evidence in the records available to substantiate the coding of G93.40.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate diagnosis code. Diagnosis code G93.40 is defined as "Encephalopathy, unspecified". In this case, you billed the services provided March 3, 2018, to March 9, 2018 with diagnosis code G93.40. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of diagnosis code G93.40 is not supported by the records provided. Our physician reviewer found that the enrollee is noted to have presented with encephalopathy on a prior admission. There is no evidence that the enrollee had acute encephalopathy during this admission. Therefore, the billing of encephalopathy (G93.40) as a secondary diagnosis is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate diagnosis code G93.40. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from March 3, 2018, to March 9, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral for endoscopic retrogradecholangiopancreatography (ECRP). You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the services requested do not need a higher level of care. 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 referral is not considered medically reasonable and necessary in this case. Our physician reviewer found the records support several comorbidities, none of which absolutely contraindicate against performance of ERCP in an outpatient non-tertiary care setting. Indeed - the enrollee has been granted cardiac clearance in anticipation of this service. 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 tertiary level referral for endoscopic retrograde cholangiopancreatography (ECRP).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extraction, erupted tooth requiring removal of bone and/or section of tooth 1, 2, 3, 4, 12, 14, 18, 29, 30, 31.
You asked the Plan to pre-approve the dental services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the service is not a covered benefit under the 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 extraction, erupted tooth requiring removal of bone and/or section of tooth 1, 2, 3, 4, 12, 14, 18, 29, 30, 31.