Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the adult sized disposable incontinence product, brief/diaper, large (T4523).
You asked the Plan to pre-approve incontinence supplies. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve the adult sized disposable incontinence product, brief/diaper, large (T4523).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical magnetic resonance imaging (MRI) (72141).
You asked the Plan to pre-approve a cervical MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated for the enrollee at this time.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a cervical MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the physical exam does not indicate any cervical pathology and the enrollee has not completed physical therapy. 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 cervical MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical magnetic resonance imaging (MRI) (72141).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section. 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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity cellulitis and bacteremia. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary
rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
You asked the Plan to pre-approve a CT scan of the chest. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have 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. Our reviewer says that the requested imaging service is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 65-year-old male with a history of asthma, type 2 myotonic dystrophy, hypertension, ventricular tachycardia, and post Aortic Valve Replacement in 2019. Per the documentation, the enrollee was referred to Pulmonology for evaluation of persistent SOB, associated with wheezing and dry cough. He apparently has had no cardiac work-up since 2019. In this case, there is no clinical rationale for the requested chest CT scan. The enrollee should undergo evaluation by Cardiology. 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 CT scan of the chest have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the chest (71250).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Percepta Bronchial Genomic Classifier (BCG) testing
you received on January 13, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that Percepta Bronchial Genomic Classifier (BCG) is
covered for the indications established in the applicable LCD.
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 testing. Our reviewer says that the
requested testing is not medically reasonable and necessary in this case. Our physician reviewer found that the
enrollee is a 68-year-old male. Lung nodules were seen on imaging, and bronchoscopy was performed with
biopsy, showing no malignant cells. Percepta Bronchial Genomic Classifier was ordered for the lung nodules.
Based on the biopsy clearly showing benign tissue, which is diagnostic, this does not meet criteria for the
Percepta Bronchial Genomic Classifier test.
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 pay for the Percepta Bronchial Genomic Classifier (BCG) testing you received on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tertiary level referral for breast surgery follow-up visits.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says this request is a yearly routine follow-up visit.
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 referral. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found you are able to be followed by an in-network provider. Tertiary care would be for your own comfort only and would be precluded 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 referral have not been met. Therefore, we decided that the Plan does not have to pre-approve a tertiary level referral for breast surgery follow-up visits.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this procedure is medically necessary.
The Plan denied your request. The Plan says the requested procedure is considered
experimental/investigational.
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 Vertiflex procedure. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and
efficacy of the device.
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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the pelvis (72192).
You asked the Plan to pre-approve a CT scan. You say that this is necessary to diagnose the enrollee. The Plan denied your request. The Plan says this is not medically necessary.
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. Our reviewer says that the requested CT scan is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a right inguinal hernia on physical examination. The record does not indicate how the CT scan would alter management. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the pelvis (72192).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (61623) provided on January 12, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this billed service is not supported.
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 61623 is "Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion".
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 services. Our reviewer says that the use of code 61623 is not supported by the records provided. Our reviewer found that the operative report does not document this procedure, and therefore cannot be confirmed as performed. Post-op documents that a "status post balloon test occlusion" procedure was documented in the operative note. 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 the services (61623) provided on January 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the cervical spine for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your
request. The Plan says there has been no worsening of symptoms or new focal neurological deficits.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the
requested MRI is not medically reasonable or necessary. Our physician reviewer found the record indicates that
the enrollee experienced an injury two weeks prior to presentation. The record indicates that the enrollee has
neck pain with right thumb and index finger numbness since December 2020. The record does not indicate any
acute onset neurological deficit. The enrollee has been undergoing physical therapy with improvement. The
record submitted does not support the medical necessity or reasonableness, as defined by Medicare rules, of the
requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied.
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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the cervical spine for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically 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 improving and only requires short-term additional acute care services which will likely take less than 25 days and can safely be administered at the current facility prior to being transferred to a lower level of care. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services is not supported and will be considered not medically necessary as there would be no significant advantage to transfer 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 in the Medicare rules section. 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for weakness and confusion. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive,
multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy procedure (0275T).
You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for the requested procedure have not been met.
The Plan follows Medicare rules. Medicare rules say that PILD will be covered when provided in a clinical study. 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 percutaneous laminotomy/laminectomy. Our reviewer says that the requested procedure is not medically necessary in this case. Our physician reviewer found that percutaneous laminectomy remains experimental for treatment of lumbar disc problems. More research is needed to show safety and efficacy of the procedure. 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 percutaneous laminotomy/laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy procedure (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care, per day, for the evaluation and management of a patient (99223) provided October 1, 2020.
You asked the Plan to pay for the initial hospital care. You say that this service was medically necessary. The Plan denied your request. The Plan says the documentation provided does not support the billing of 99223.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with 99223 - Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. We asked our coder 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 initial hospital care. Our reviewer says that the services provided on October 1, 2020, do not meet criteria for billing or reimbursement consideration. Our coder reviewer found that the documentation received was reviewed and it was determined that the records did not support the coding criteria for the code billed under 99223: A comprehensive history, comprehensive examination, medical decision making of high complexity. The medical decision making was not of high complexity. The review has determined that the medical record did not support the billing of 99223 for October 1, 2020. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the initial hospital care, per day, for the evaluation and management of a patient (99223) provided October 1, 2020.
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 this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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