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

We decided that the Plan does not have to pre-approve a computed tomography perfusion (CTP) of the brain.
You asked the Plan to pre-approve a CTP of the brain. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that CTP (using automated post-processing software algorithmic analysis) is medically reasonable and necessary in patients with small acute ischemic stroke (AIS) caused by a unilateral large vessel occlusion (LVO) in the proximal anterior circulation evaluated at stroke centers. 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 CTP of the brain. Our reviewer says that the services are not medically necessary. Our physician reviewer found in this case, the record indicates that the enrollee was referred as an outpatient for evaluation of memory and cognitive deficits. The record does not indicate that the enrollee is a candidate for endovascular intervention for an acute ischemic event. The elements of the coverage rule 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 a CTP of the brain have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography perfusion (CTP) of the brain.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental implants (D6010) for teeth #4, #5, #8, and #9.

You asked the Plan to pre-approve the implants. You say that the enrollee lost these teeth to gum disease, and implants are necessary to restore masticatory function. The enrollee is also unable to wear dentures due to an impaired ability to keep the dentures clean. The Plan denied your request. The Plan says generally implants are only covered when they are medically necessary and are requested to replace a single tooth in an arch (not including wisdom teeth). These implants are denied because the records show that the enrollee is missing more than one tooth in this arch of the mouth. In addition, implants are more difficult to maintain and keep clean than a removable prosthetic. 

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 Plan covers implants when the services are medically necessary and reasonable, and there is only a single tooth missing in an arch or the implants are medically necessary to support a complete denture. 

We looked at the file and Medicare rules. These implants are requested to replace four teeth in the same arch. The Plan will only cover implants to replace a single tooth in one arch. In addition, no documentation was provided regarding the impairment that makes it so the enrollee cannot wear dentures. Based on this information, we decided that the Plan's rules for coverage of the implants have not been met. Therefore, we decided that the Plan does not have to pre-approve dental implants (D6010) for teeth #4, #5, #8, and #9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99213) provided December 9, 2020.

You asked the Plan to pay for the office visit. You say that this was an auto claim, and you need the Plan to pay the balance due. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.

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 outpatient office visit (99213) provided December 9, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a hybrid convergent MAZE ablation procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that the patient presents with persistent atrial fibrillation despite medication adjustments, previous catheter ablations and cardioversion. The Plan denied your request. The Plan says that that it has not been established that the Hybrid Convergent procedure meets the member's care needs and is both safe and effective.

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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. The patient has had multiple prior attempts at rhythm control with repeated cardioversions, antiarrhythmic drug therapy and a number of percutaneous atrial fibrillation ablation procedures but he continues to have multiple symptomatic recurrences of atrial fibrillation. In addition, anti-coagulation has been difficult (history of lupus anticoagulant) putting him at higher risk for embolic stroke in the setting of recurrent atrial fibrillation. Although hybrid convergent (surgical MAZE/percutaneous ablation) procedures do not have large volumes of acute or long-term follow up data at this time, both procedures individually have been shown to be effective and there are smaller randomized trials to recommend the use of this technology especially when there is evidence of extra-pulmonary vein etiology of the atrial fibrillation, but not as initial first line therapy. However, in this situation, the patient has repeatedly failed traditional medical management and percutaneous techniques making him a recurrent treatment failure candidate. In this specific clinical situation then, there is enough published data to recommend the use of a hybrid convergent MAZE ablation procedure as medically reasonable and necessary. Our physician reviewer found that the enrollee's condition meets criteria for these 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a hybrid convergent MAZE ablation procedure for the enrollee.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the aflibercept injection (J0178) provided on February 24, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 20% coinsurance for Medicare Part B prescription drugs rendered by an in-network provider. You have been asked to pay $368.70 (Plan allowed amount of $1,843.52 x 20% coinsurance) for the Medicare Part B drug injection provided.
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 coinsurance for the aflibercept injection (J0178) provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the carpal tunnel injection provided on February 1, 2021
You asked the Plan to pay for the carpal tunnel injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 20526 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the carpal tunnel injection have not been met. Therefore, we decided that the Plan does not have to pay for the carpal tunnel injection provided on February 1, 2021
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a prosthetic leg with an electronic knee, advanced foot and other parts (L5828, L5856, L5850, L5925).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the request was approved on prior review, except for the K3 components.
The Plan must follow Medicare rules. Medicare rules say that leg prostheses are covered based on functional levels. 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 services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided, there is documentation from the prescribing provider that you have the ability to ambulate and the potential to a level 3 ambulator. This would justify the request for a K3 prosthesis. The records from the provider do state that the microprocessor knee is recommended as detailed in the provider's treatment plan. 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 pre-approve a prosthetic leg with an electronic knee, advanced foot and other parts (L5828, L5856, L5850, L5925).
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided from January 13, 2020, through January 14, 2020.

You asked the Plan to pay for the hospital services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.

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 hospital services provided from January 13, 2020, through January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, and 81321 provided on September 30, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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 find that CPT codes 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, and 81321 are not supported in the medical record. Specifically, the documentation shows that the enrollee had molecular pathology testing on September 30, 2020. When a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedure service, so only one code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311, 81317, and 81321 provided on September 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an outpatient surgery. You say that you would like approval for these services to be provided by an out-of-network provider. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an outpatient surgery to be provided by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on February 23, 2021.

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 procedure code 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on February 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract eye surgery for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements were not met.
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 surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee has a cataract which is causing symptomatic impairment of visual function which is resulting in specific activity limitations and/or participation restrictions including, but not limited to reading, viewing television, driving, or meeting vocational or recreational 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve cataract eye surgery for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient minimally invasive lumbar laminectomy and PLIF (posterior lumbar interbody fusion) with donated bone and instrumentation with iliac crest autograft for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of these services has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no documentation of adequate conservative measures to include a recent trial and failure of physical therapy for back pain. More conservative measures are needed. Our physician reviewer found that the enrollee's condition does not meet criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient minimally invasive lumbar laminectomy and PLIF (posterior lumbar interbody fusion) with donated bone and instrumentation with iliac crest autograft for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210), and an unspecified preventive procedure (D1999) provided on February 16, 2021.
You asked the Plan to pay for an intraoral complete series of radiographic images, and an unspecified preventive procedure. You say that you do not agree with the charges. The Plan denied your request. The Plan says the services at issue are not covered benefits.
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 pay for an
intraoral complete series of radiographic images (D0210), and an unspecified preventive procedure (D1999) provided on February 16, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezia.

You asked the Plan to pre-approve Otezia. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Otezia.

Benefits for Otezia may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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 this is the safest discharge plan and it allows for the highest potential level of recovery. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 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. The patient is currently undergoing treatment at an acute care hospital (ACH) for Coronavirus. The enrollee was intubated/ventilated and subsequently received a tracheotomy. Weaning trials are being performed. 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 needs. 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.