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

We decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95810).
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been 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 polysomnography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation is insufficient to demonstrate that repeat Polysomnography is medically reasonable and necessary for the enrollee 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 polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep (95810).
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 IRF care is medically necessary. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Rehabilitation care could be arranged for at home or in an outpatient 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 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: 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 you will not get better without aggressive therapy. The Plan denied your request. The Plan says your care can be provided in the current 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 the documentation does not support that you requires service at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH that are not available at the current health care setting being offered by the health 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 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 referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are 19 in-network providers within a 20-mile radius of your zip code.
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 a referral to an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization services (37224 and 37222) provided on January 20, 2020.
You asked the Plan to pay for the revascularization services. 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 37224 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. The CPT Code Manual definition of code 37222 is revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral iliac vessel; with transluminal angioplasty (List separately in addition to code for primary 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 revascularization services. Our reviewer says that CPT codes 37224 and 37222 do not meet criteria for billing or reimbursement consideration. Our reviewer found documentation of CPT codes 37224 and 37222 was not included in the operative report submitted. 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 revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for revascularization services (37224 and 37222) provided on January 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an epidurography (72275) provided on January 15, 2020.
You asked the Plan to pay for the epidurography. 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 service 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 72275 is epidurography, radiological supervision and interpretation. 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 epidurography. Our reviewer says that CPT code 72275 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of Epidurography radiological supervision and interpretation being performed on January 15, 2020. 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 epidurography have not been met. Therefore, we decided that the Plan does not have to pay for an epidurography (72275) provided on January 15, 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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 receiving care at an acute care hospital. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve outpatient physical therapy. You say that due to a lack of transportation the
enrollee is not able to go to other facilities. The Plan denied your request. The Plan says the denial of
authorization for these services is correct, because this provider is out-of-network with the Plan and the
enrollee can be treated by an in-network 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 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
the medical services to be provided by an out of network (OON) provider.
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 services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee is ambulating household distances. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug provided on January 20, 2020.
You asked the Plan to pay for the self-administered drug. You say that the drug was administered to you while under general anesthesia. The Plan denied your request. The Plan says the drug is not covered under your Medicare Part B benefit.
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 pay for the self-administered drug provided on January 20, 2020.
Benefits for the self-administered drug 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve positron emission tomography (PET) scan services.
You asked the Plan to pre-approve the PET scan services. You say that the records provided support the need for the requested PET scan. The Plan denied your request. The Plan says that, before they can approve the request, they need to see notes show the findings of the LDCT that was already approved. The Plan say that this information was not included in the information they received.
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 the PET scan services. Our reviewer says that the PET scan is medically reasonable and necessary. Our physician reviewer found a PET scan is indicated to characterize lesions. A biopsy would be of significant risk. A PET scan can hopefully better characterize the lung lesions. 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 PET scan services have been met. Therefore, we decided that the Plan has to pre-approve positron emission tomography (PET) scan services.
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: Favorable

We decided that the Plan has to pre-approve LTACH services, for the enrollee.
You asked the Plan to pre-approve LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says that the stay is 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 LTACH services. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found ongoing inpatient needs include close monitoring of respiratory status and continuous cardiac
monitoring, as well as occupational therapy/physical therapy and speech services. Continued acute inpatient
hospital care is 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 LTACH services have been met. Therefore, we decided that the Plan has to preapprove
LTACH services, 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 pay for nerve conduction studies (95911) and needle electromyography (95886) provided on April 15, 2019.You asked the Plan to pay for the nerve conduction studies and needle electromyography. 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 95911 is nerve conduction studies; 9-10 studies.The CPT Code Manual definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary 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 nerve conduction studies and needle electromyography. Our reviewer says that CPT code 95911 does not meet criteria for billing or reimbursement consideration.  The documentation does support 9-10 studies, a more appropriate code would be used. Our reviewer found CPT code 95886 does not meet criteria for billing or reimbursement consideration. This code is denied because the primary code is denied.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 nerve conduction studies and needle electromyography have not been met.Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95911) and needle electromyography (95886) provided on April 15, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 physical therapy (PT) visits.
You asked the Plan to pre-approve 8 PT visits. You say that the services are necessary. The Plan denied your
request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been
met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 8 PT visits. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition.
Our physician reviewer found for muscle weakness and impaired mobility, PT is generally accepted as specific
and effective therapy. Goals include restoring function, and educating regarding a home exercise program
(HEP) prior to transition towards a home program. In this case, there is no indication residual deficits following
PT, could not be addressed via a home exercise program. Therefore, this request is deemed not 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 8 PT visits have not been met. Therefore, we decided that the Plan does not
have to pre-approve 8 physical therapy (PT) visits.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a bronchoscopy (31624) provided on November 7, 2019.
You asked the Plan to pay for the bronchoscopy. 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 service 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 31624 is bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial alveolar lavage. 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 bronchoscopy. Our reviewer says that CPT code 31624 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not indicate that this procedure was 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 bronchoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a bronchoscopy (31624) provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a retrobulbar injection (67500) provided on December 10, 2019.
You asked the Plan to pay for the retrobulbar injection. You say that you would like reconsideration because
this service was rendered by a separate provider. The Plan denied your request. The Plan says that the surgical
code was submitted by a provider with an anesthesia specialty.
The Plan must follow Medicare rules. Medicare 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.
We find that CPT code 67500 is supported in the record. Specifically, this service was rendered by a provider
different than the provider which furnished the anesthesia service, meaning that the PTP edit between the two
codes cannot be applied. In addition, the citation from Chapter 8 of the NCCI Policy manual appears to apply
to injection codes billed by the provider of the ophthalmic procedure and cannot be applied to services rendered
by a CRNA in support of the ophthalmic procedure. The Medicare rules referenced by the Plan do not state that
the provider type at issue cannot bill for code 67500. The denial is not substantiated and we must find in your
favor. Therefore, we decided that the Plan has to pay for a retrobulbar injection (67500) provided on December
10, 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.