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

We decided that the Plan does not have to pay for the removal of spinal lamina (63048x2) provided on August 28, 2019.
You asked the Plan to pay for the removal of spinal lamina. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the number of units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the removal of spinal lamina. Our reviewer says that CPT code 63048x2 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical record provided does not include documentation to support billing 2 units of laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) for August 28, 2019, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the removal of spinal lamina have not been met. Therefore, we decided that the Plan does not have to pay for the removal of spinal lamina (63048x2) provided on August 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-approve IRF care. You say that the records provided support that the enrollee needs the requested level of care. The Plan denied your request. The Plan says the criteria for coverage of IRF care have not been met and the requested services are not medically necessary.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee will be limited by his weight bearing status and external fixator device. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee's providers are recommending
the SNF treatment to get her strength back up and for some additional care to get better. You say that the
enrollee is currently back at her assisted living facility and that, due to Covid-19, you have not been able to
provide the daily care that you were previously able to provide. You say that you are trying to keep the
consistent care to assist with the enrollee's dementia issues and recovery. The Plan denied your request. The
Plan says the enrollee does not require complex daily nursing care or daily skilled rehabilitation therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral
medications, had stable vital signs, and was alert with confusion. The enrollee received physical therapy and
occupational therapy in the acute hospital. The enrollee was dependent for functional mobility, which was her
baseline. The enrollee was dependent with activities of daily living, except for self-feeding. There are no
identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee
does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing
facility setting.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve continued use of One Touch Verio test strips (A4253).
You asked the Plan to pre-approve continued use of One Touch Verio test strips (A4253). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says that One Touch Verio test strips are not preferred test strips for the Plan.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the plan has not provided any medical records or evidence of having made reasonable attempts to obtain this necessary documentation. Without this information, we are unable to assess whether the continued used of the current test strips is medically necessary and appropriate to ensure continuity of care and adequate treatment of the enrollee's medical needs. The plan has not substantiated their denial. Furthermore, the Evidence of Coverage that the Plan provided does not show any limitations apply on the approval of supplies to monitor blood glucose levels. Therefore, we decided that the Plan has to pre-approve continued use of One Touch Verio test strips (A4253).
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 pre-approve genetic testing for fibromyalgia.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your
request. The Plan says there is not enough published scientific evidence to show that this test is effective at
diagnosing fibromyalgia.
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 testing. Our reviewer says that the
requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer
found no provider records have been submitted for review. Therefore, there is no evidence to support that the
requested service is medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's
condition(s).
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 testing have not been met. Therefore, we decided that the Plan does not have
to pre-approve genetic testing for fibromyalgia.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Test Strips.You asked the Plan to pre-approve the One Touch Ultra Test Strips. You say that the test strips are medically necessary.The Plan denied your request. The Plan says A 3 month supply has been approved to transition to the plan preferred brand. There is no reason in the records why the enrollee cannot use the preferred brand.The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred brands.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 One Touch Ultra Test Strips. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the medical records provided show no reason why the plan preferred brand is not appropriate 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 One Touch Ultra Test Strips have not been met.Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Test Strips.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia injections (J0897). You asked the Plan to pre-approve Prolia. You say that the Prolia is medically necessary. The Plan denied your request. The Plan says a failed trial of Zoledronic acid is required before drugs like Prolia can be considered. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Prolia. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee's records do not show a plan required trial of Zoledronic acid, or any reason it would be unsafe or ineffective 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia injections (J0897).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says LTACH care is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a diabetic foot ulcer. The enrollee has undergone partial amputation of his left big toe. The enrollee continues to receive wound care and antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
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 records do not support the need for daily therapy on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the provided medical records do not indicate a need for skilled nursing services. The provided medical records do not indicate a need for inpatient services. Care in the home or an assisted living facility with home health services appears to be appropriate. 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 continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (CPT 15734) provided to the enrollee on October 28, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this code cannot be verified.
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 15734 is "Muscle, myocutaneous, or fasciocutaneous flap; trunk". 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 reviewers says that the use of CPT code 15734 is supported by the records provided? Our physician reviewer found that the operative note supports completion of a bilateral rectorectus release by mobilizing the fascia of the external oblique muscles bilaterally to allow for tension free closure. This is otherwise described as component separation technique and the appropriate CPT code is 15734 which is supported in the operative report. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 15734 have been met. Therefore, we decided that the Plan has to pay for the services (CPT 15734) provided to the enrollee on October 28, 2019.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for(A4217), (A4452), (A4550), (A4649), (A6204), (A6209) and (A6448) provided to the enrollee on August 19, 2019.You asked the Plan to pay for the DME. You say that the services are medically necessary.The Plan denied your request. The Plan says these items are considered bundled into the original CPT code or statutorily excluded from coverage according to the National Correct Coding Initiative (NCCI) Manual.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Based on Medicare guidelines the items that you requested including dressings, saline, bandages and surgical trays (A4217, A4452, A4550, A4649, A6204, A6209, A6448) that you or your provider are requesting do not meet requirements for approval. These items are considered bundled into the original CPT code or statutorily excluded from coverage according to the National Correct Coding Initiative (NCCI) Manual.Therefore, we decided that the Plan does not have to pay for(A4217), (A4452), (A4550), (A4649), (A6204), (A6209) and (A6448) provided to the enrollee on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says step therapy exception criteria were not met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee does not have a history of an osteoporotic fracture. Additionally, documentation does not support the enrolle has trialed zoledronic acid. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reason this medication was not considered. Without the support of the documentation, Prolia is not approved as step criteria is not met. 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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for x-rays (73503, 71100, 71046) and a CT Scan (72125) provided on December 19, 2019.
You asked the Plan to pay for the x-rays and CT Scan. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the diagnosis code can only be the primary.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to forward sufficient information to verify what diagnosis code is at issue and why. We are unable to substantiate the Plan's denial. Therefore, we decided that the Plan has to pay for x-rays (73503, 71100, 71046) and a CT Scan (72125) provided on December 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility care provided from July 11, 2019 to July 24, 2019.
You asked the Plan to pay for the inpatient skilled nursing facility care provided July 11, 2019 to July 24, 2019.
You say that you are a representative for the State and are requesting a reconsideration for the
services paid for byMedicaid. The Department of Social Services is authorized to
pursue Medicare Claims for services provided to dually eligible Medicare and Medicaid beneficiaries and for
which the state Medicaid program has paid. The Plan denied your request. The Plan says the inpatient skilled
nursing facility care provided is paid for by Original Medicare as the member was enrolled in hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the inpatient skilled nursing facility care provided from July 11, 2019 to July 24, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a transthoracic echocardiography (TTE) test.
You asked the Plan to pre-approve TTE test. You say that you are appealing with medical records. The Plan
denied your request. The Plan says that the denial of authorization for this service is correct, because the
clinical documentation submitted does not support coverage.
The Plan follows Medicare rules. Medicare rules say that evaluation of a suspected cardiomyopathy is a
covered indication for transthoracic echocardiography (TTE).
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 TTE test. Our reviewer says that the
enrollee meets the Medicare criteria for the requested TTE test. Our physician reviewer found based on the
records the enrollee has increased cardiac risk, new dyspnea symptoms concerning for possible
cardiomyopathy, and a history of alcohol abuse known to be a cause of cardiomyopathy. Under these
circumstances an echocardiogram is medically reasonable and appropriate to assess for cardiomyopathy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of TTE test have been met. Therefore, we decided that the Plan has to pre-approve
a transthoracic echocardiography (TTE) test.
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.