Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided September 14, 2019 to September 19, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the care and treatment provided during the relevant dates meets the definition of medically necessary as evidenced by the medical records submitted. The Plan denied your request. The Plan says that per neurology guidelines criteria was not met. The continued stay did not meet as there was no neurological assessment or neurological impairment or condition which required neurological assessment. The services could have been transferred back to the assisted living after the emergency department (ED) evaluation and treatment.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment were met in this case. Our physician reviewer found the enrollee presented to the ED on September 14, 2019 following a fall at an assisted living facility. His blood pressure on the scene was low. He was given intravenous (IV) fluids. He had an altered mental status and was agitated with combative behavior. The facility staff stated he has had urinary incontinence, gait instability, combativeness, and agitation. He had a medical history of Alzheimer's dementia, congestive heart failure, diabetes, Parkinson's disease, prostate cancer, and a pacemaker. On September 18, 2019 he was pending skilled nursing facility placement. On September 19, 2019, he was back at baseline and more alert. He was discharged back to the memory care unit. The review has determined that the care and treatment provided during the relevant dates meets the definition of medically necessary as evidenced by the medical records submitted. Based on the documentation in the case file, it was reasonable for the admitting physician to expect that this enrollee's necessary medical would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided September 14, 2019 to September 19, 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 pre-approve a vitrectomy chair (E1399).You asked the Plan to pre-approve a vitrectomy chair. You say that you need the item for your recovery post eye surgery.The Plan denied your request. The Plan says the item is not primarily medical in nature. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve a vitrectomy chair (E1399).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis.
You asked the Plan to pre-approve the CT scan. You say that the last imaging done was in July of 2019. You
say that the enrollee has imaging and MD follow-up scheduled. The Plan denied your request. The Plan says
that the records do not show enough details to determine whether imaging would be needed, and what type
would be most helpful.
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 CT scan is medically necessary. Our physician reviewer found there is no evidence to guide the posttreatment
surveillance strategy in enrollees with pancreatic cancer or for enrollees with resected pancreatic
cancer. Our physician reviewer found that the enrollee completed treatment in February of 2019. Our physician
reviewer found that there is no consensus from expert groups. Our physician reviewer found that surveillance
CT scans of the abdomen/pelvis every 3-6 months for the first 2 years is category 2B from the NCCN
Guidelines. Our physician reviewer found that many experts do perform surveillance CT scans and that, given
the last one was about 6 months ago, a repeat scan is reasonable and medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the CT scan have been met. Therefore, we decided that the Plan has to preapprove
computed tomography (CT) scan of the abdomen and pelvis.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided to the enrollee on January 9, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the enrollee exhausted their benefit frequency limit.
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. The enrollee exhausted their benefit frequency limit, because they had this service on January 2, 2020. Therefore, we decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) provided to the enrollee on January 9, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).You asked the Plan to pre-approve a PET CT scan from the skull base to mid-thigh. You say that the service is necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that PET 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 PET CT scan from the skull base to mid-thigh. Our reviewer says that the service is medically necessary. Our physician reviewer found the requested Axumin PET/CT is not for staging. The widespread bone metastases evident on bone scan has already provided the staging as well as the CT. Axumin is prostate tissue specific so it will be a valuable tool to evaluate subsequent treatment/success or failure. Importantly, the enrollee has significant left temporomandibular joint (TMJ) pain. If the Axumin scan is positive in that area the pain can then be ascribed to metastasis and targeted treatment may be feasible. Note that conventional bone scanning will remain positive for a long time even if treatment is successful whereas the Axumin PET scan can provide evidence via standardized uptake value (SUV) if the polyostotic lesions are responding to planned 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 PET CT scan from the skull base to mid-thigh have been met.Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan from the skull base to mid-thigh (78815).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 long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 CoViD-19 infection. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is currently tolerating ventilator weaning trials. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion consultation.
You asked the Plan to pre-approve the consultation. You say that this is medically necessary. The Plan denied your request. The Plan says neuroendocrine oncology services are available.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 consultation. Our reviewer says that the requested consultation is not medically reasonable or necessary. Our physician reviewer found per the claims data, the enrollee has not been evaluated and treatment of neuroendocrine tumors is available in the Medical Oncology department. At this time there is no specific medical indication for the for the enrollee to go out of area to receive a second opinion. The requested out-of-area second opinion is not medically necessary and reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the consultation have not been met. Therefore, we decided that the Plan does not have to pre-approve a second opinion consultation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy (97124) provided on December 4, 2019.You asked the Plan to pre-approve massage therapy. You say that this service provided relief for your back pain.The Plan denied your request. The Plan says this service is not covered.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pre-approve massage therapy (97124) provided on December 4, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for decompression fasciotomy (25020) and arthroscopy (29830) provided on July 15, 2019.
You asked the Plan to pay for the decompression fasciotomy and arthroscopy. 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 services 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. In this case, the CPT Code Manual definition of code 25020 is decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve. The CPT Code Manual Definition of code 29830 is arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure). 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 decompression fasciotomy and arthroscopy. Our reviewer says that CPT code 25020 does not meet criteria for billing or reimbursement consideration. The description of 25020 was not documented in the operative report, therefore this service cannot be verified. Our reviewer found CPT code 29830 does not meet criteria for billing or reimbursement consideration. CPT 29830 would be used when the surgeon just looks in the Elbow joint but does not perform any surgical procedure. In this case, the record does not indicate that this was the service performed.
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 decompression fasciotomy and arthroscopy have not been met. Therefore, we decided that the Plan does not have to pay for decompression fasciotomy (25020) and arthroscopy (29830) provided on July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan injections (J7321). You asked the Plan to pre-approve Hyalgan. You say that the Hyalgan injections are medically necessary. The Plan denied your request. The Plan says a trial of plan preferred agents Orthovisc and Monovisc is required before alternatives like Hyalgan 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 Hyalgan. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the records provided do not show any reason why the plan preferred drugs - Orthovisc and Monovisc - would be ineffective or unsafe for the 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan injections (J7321).
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve arthrodesis (22614).
You asked the Plan to pre-approve the arthrodesis. You say that this procedure is medically necessary to treat the member's condition. The Plan denied your request. The Plan says that the notes do not show that the member has failed conservative treatment and has instability at all of the levels to be fused.
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 arthrodesis. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guidelines support fusion in this enrollee's clinical scenario given her progressively worsening symptoms, neurologic deficits, imaging evidence of multilevel listhesis, moderate to severe L2/3 and L3/4 stenosis with prior L2 and L3 kyphoplasties, levoscoliosis, and probable pseudoarthrosis at L5/S1. There reasonable need for wide decompression at L2/3 and L3/4 that would result in temporary intraoperative instability and necessitate fusion. 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 arthrodesis have been met. Therefore, we decided that the Plan has to pre-approve arthrodesis (22614).
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 pay forthe infectious agent detection rendered on November 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed with an allowed diagnosis.The Plan must follow Medicare rules. The rules say that one of a specific list of diagnosis codes must be billed with procedure code 87507. We looked at the file and Medicare rules. The file shows that procedure code 87507 was not billed with one of the diagnosis codes listed as required in the 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 pay forthe infectious agent detection rendered on November 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital transfer.
You asked the Plan to pre-approve an inpatient hospital transfer. You say that the requested inpatient hospital transfer is medically necessary. The Plan denied your request. The Plan says the requested inpatient hospital transfer is not medically necessary.
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 an inpatient hospital transfer. Our reviewer says that the requested inpatient hospital transfer is not medically necessary. Our physician reviewer found in the case of this enrollee, although admission for severe chronic obstructive pulmonary disease (COPD) exacerbation and respiratory failure led to acute care, current records state that he was looking much better with improved mental status, improved breathing, and was able to move out of the ICU. The enrollee showed need for therapy as well as short term additional acute care for pulmonary stability prior to discharge home or to a lower level of care. Transfer to another acute care facility would be needed as only a short duration of acute care was likely remaining, based on the provided recent notes. As soon as stable, he should be able to discharge to a lower level of care. Therefore, without significant benefit predicted from transferring so late in the course of treatment, this request for transfer will be considered not medically necessary 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 an inpatient hospital transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital transfer.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for injection services (CPT 64492) provided to the enrollee on October 24, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that Current Procedural Terminology (CPT) code 64492-LT remains 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 64492 is "Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)." 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 services at issue in this case were coded correctly. Our physician reviewer found on 10/24/2019 it appears that the enrollee received three thoracic, articular joint injections. The injections were performed at T9, T10 and T11. While the locations would be better described as T9/10, T10/11 and T11/12, it does appear that three injections were provided. Therefore, the billing of CPT 64492, which indicates the third injection is supported. It should also be noted that the health plan's denial is unclear as to what aspect of the code/documentation is not supported. 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 been met. Therefore, we decided that the Plan has to pay for injection services (CPT 64492) provided to the enrollee on October 24, 2019.