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

We decided that the Plan has to pre-approve high-intensity focused ultrasound (HIFU) of the prostate.
You asked the Plan to pre-approve the HIFU procedure. You say that it is felt that this treatment should be allowed. The Plan denied your request. The Plan says that the requested services are 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 the HIFU procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has stage T1c Gleason grade 3+4 prostate cancer in 4 of 13 cores. High Intensity Focused Ultrasound (HIFU) treatment of the prostate is neither experimental nor investigational. Numerous clinical studies have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower risk of side effects such as impotence, incontinence, and bowel injury. HIFU is widely accepted in the international medical literature as both a primary and salvage treatment for prostate cancer. HIFU was FDA cleared on October 9, 2015 for prostate ablation and the first United States treatment outside of FDA trials was performed on November 10, 2015. 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 HIFU procedure have been met. Therefore, we decided that the Plan has to pre-approve high-intensity focused ultrasound (HIFU) of the prostate.
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 pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs ventilator weaning in a LTACH setting which will take 4-6 weeks. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services do not meet the requirements for approval.

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 that the enrollee is a 74-year-old male with a history of congestive heart failure and hypertension who came to the hospital June 5, 2021 for breathing problems due to a recently diagnosed COVID-19 infection. The medical record indicates that the enrollee needed a ventilator machine intermittently to help him breathe, and through a tracheostomy tube. He has been treated with intravenous steroids and antibiotic medications, as well as inhaled medications to improve his breathing, and an anti-interleukin-6 receptor medication. Notes from the enrollee's physician, 4 days ago, stated that they were concerned he may have blood clots in his lungs, and he was started on an infusion of heparin. There is no documentation provided necessitating 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 LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tresiba Flex.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tresiba Flex.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81185, 81238, 81286, 81403, 81404, 81405, 
81406, 81410, 81411, 81439, 81479) provided September 26, 2020. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this is not a covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
risk assessment panels, except for the basic lipid panel, for symptomatic patients with suspected or documented 
cardiovascular disease. 
 
We looked at the file and Medicare rules. This service is not covered under Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81185, 81238, 81286, 81403, 81404, 81405, 81406, 
81410, 81411, 81439, 81479) provided September 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on February 8, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 
benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the chiropractic services provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 1, 2021, by an OON 
provider. 
 
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan 
denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior 
authorization was not obtained by a participating provider. 
 
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. 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 lab work provided on February 1, 2021, by an 
OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87511, 
87529, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on February 1, 2021. 
 
You asked the Plan to pay for laboratory services. You say that these services should be covered as in-network. 
The Plan denied your request. The Plan says these services were billed with an incorrect POS code.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS). 
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the records show that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that 
the Plan does not have to pay for laboratory services (87150, 87481, 87491, 87500, 87511, 87529, 87591, 
87640, 87641, 87651, 87653, 87661, 87798, 87801) provided on February 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and 
does not require transfer to LTACH. 
 
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. The enrollee 
was admitted following cardiac arrest due to mucous plugging and acute on chronic hypoxic respiratory failure. 
The enrollee continues to receive acute care services and these have not been denied. The medical record does 
not indicate that the enrollee requires services that she is not currently receiving but that would be available at 
the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for LTACH services. 
 
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on August 27, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says 158 units of procedure code 01402 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 01402 is anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty. 
 
We find that 158 units of CPT code 01402 is not supported in the medical record. Specifically, the records 
show that only 147 units of this code were performed. Based on this information, we decided that Medicare 
rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to 
pay for the anesthesia services rendered on August 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oncology (prostate), promoter methylation profiling by 
real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, 
algorithm reported as a likelihood of prostate cancer detection on repeat biopsy (CPT code 81551), for the 
enrollee. 
 
You asked the Plan to pre-approve the services. You say that the reviewer overlooked the following 
documented risk factor that supports approval of the prior authorization. The Plan denied your request. The 
Plan says the Medicare rules have not been 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 the services. Our physician reviewer 
found the review indicates that the required test requires the enrollee to have a core prostate biopsy with 8-24 
tissue samples of at least 20 microns in the past 24 months that shows no metastatic/ abnormal cells are present. 
The enrollee must not be managed by active surveillance for low-stage prostate cancer and must not have had 
the requested test, or a similar test, done on the tissue from the prostate gland before. The clinical 
documentation submitted does not include the information required to meet the guidelines for criteria needed 
for the requested service. The review has determined that the medical records provided do not meet the 
requirements listed in the LCD for Medicare coverage. 
 
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 oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, 
APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of 
prostate cancer detection on repeat biopsy (CPT code 81551), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided 
November 28, 2019 to December 27, 2019. 
 
You asked the Plan to pay for the SNF services. You say that you feel that the SNF services should be covered 
by the Plan. The Plan denied your request. The Plan says the 100-day SNF benefit has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from July 12, 2019 to 
November 28, 2019. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pay for the skilled nursing facility (SNF) services provided November 28, 2019 to 
December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heel wedge (CPT code L3350).

You asked the Plan to pre-approve the heel wedge. You say that you had a complete hip replacement on your right hip which resulted to your operated leg to be a half inch longer than your unoperated leg. The Plan denied your request. The Plan says the heel wedge would be covered for your uneven leg length if both of the following are met: 1. They are on a shoe that is part of a brace; and 2. They are medically needed for the brace to work.

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 heel wedge have not been met. Your doctor's notes do not show that you have a brace. Therefore, we decided that the Plan does not have to pre-approve the heel wedge (CPT code L3350).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Fluid Flow injection.

You asked the Plan to pre-approve the Fluid Flow injection. You say that you would like reconsideration because Fluid Flow is the best course of treatment for the member and the only medication with the power to regenerate tissue. The Plan denied your request. The Plan says the use of Fluid Flow is not Food and Drug Administration approved and is not the standard 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 Fluid Flow injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this type of treatment does not have sufficient high-quality evidence to support its use in this specific clinical scenario according to current literature. 

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 Fluid Flow injection have not been met. Therefore, we decided that the Plan does not have to pre-approve the Fluid Flow injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702) for the enrollee.

You asked the Plan to pre-approve the device. You say that the device is medically necessary. The Plan denied your request. The Plan says a review of current medical literature shows that these service(s) do not have proven benefit and are considered experimental/investigational. The Plan states they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

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 device. Our physician reviewer found the record indicates that the enrollee underwent craniotomy due to intracranial bleed that resulted in left upper extremity weakness. The provided medical records are insufficient to demonstrate the medical reasonableness and necessity of the requested service as defined by Medicare rules. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve MyoPro Motion G Orthotic device (CPT code L8702) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 22, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that modifier -RR must be billed when DME is to be rented. Modifier -NU must be billed for durable medical equipment that is new. 

We looked at the file and Medicare rules. The file shows that the equipment was billed with modifier -NU but not modifier -RR. Medicare does not cover this equipment when not rented. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator rendered on October 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from November 11, 2020 to December 10, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claims were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that home health claims must be billed with one of three Q codes. 

We looked at the file and Medicare rules. The file shows that the claims were not billed with the required Q code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services rendered from November 11, 2020 to December 10, 2020.