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

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires medical supervision with active
monitoring, and intensive rehab therapy. The Plan denied your request. The Plan says the enrollee's rehab and
nursing needs are not complex.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for altered mental status and was treated for pneumonia. Her
medical problems are stable. 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. The
medical record supports a need for physical and occupational therapy, but it does not support a need for an
intensive rehabilitation therapy program.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT Code 64624).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says this procedure is not approvable by the Plan because it is still being studied to see if it is as good as or better than standard treatment for knee pain from osteoarthritis. 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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records indicate that the enrollee had been diagnosed with osteoarthritis of the knees. Conservative treatment has included physical therapy and corticosteroid injections with short term benefit. Current medications are not reported. The treating physician has requested right genicular nerve radiofrequency ablation to reduce knee pain, following positive genicular nerve block. However, the requested procedure is not currently supported as safe and effective by evidence-based peer-reviewed literature. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of these procedures for this enrollee as discussed above. Therefore, the request for genicular nerve radiofrequency ablation (CPT code 64624) is not medically reasonable and 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT Code 64624).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF stay.
You asked the Plan to pre-approve the SNF stay. You say that the enrollee is not able to go home because they are not able to be taken care of. The Plan denied your request. The Plan says your request for approval of admission to skilled nursing facility does not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF stay. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF stay.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT Codes 22869 and
22870).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says this service is considered experimental and investigational as it is not identified as
widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed
medical literature published in the English language.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the spacer remains experimental. More research is needed to show safety and efficacy.
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 the Superion interspinous spacer (CPT Codes 22869 and 22870).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation.
You asked the Plan to pre-approve these services. You say that you have leaky valves in your legs. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that endovenous ablation is covered when specific
criteria are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the submitted records show that you
have documented evidence of significant peripheral artery disease. The Medicare criteria require that there is
no peripheral artery disease. The criteria are not met and the requested endovenous ablation is not reasonable or
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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve endovenous ablation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer (CPT Codes 22869 and
22870).
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says this service is considered experimental and investigational as it is not identified as
widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed
medical literature published in the English language.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the device is experimental. More research is needed to show safety and efficacy.
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 the Superion interspinous spacer (CPT Codes 22869 and 22870).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CPT Code K0861, E1007, E1012 and E2311.
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your
request. The Plan says the DME is not 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 DME. Our physician reviewer
found based on the medical records provided there is no documentation that the medical records provided meet
the requirements listed in the Nation Coverage Determination/Local Coverage Determination for Medicare
coverage for the group 3 power wheelchair and accessories. The patient has no documentation of a neurological
condition, myopathy, or congenital skeletal deformity that is necessary for a group 3 power wheelchair and
accessories.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve CPT Code K0861, E1007, E1012 and E2311.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinjection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT Code 62323).You asked the Plan to pre-approvethe services. You say that the services are necessary.The Plan denied your request. The Plan says the services are not 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 services. Our physician reviewer found the lack of documentation fails to fulfill the criteria of the LCD and therefore, the request is deemed not be medically reasonable or 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveinjection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) (CPT Code 62323)
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76642) provided July 1, 2020.
You asked the Plan to pay for the ultrasound. You say that the service was medically necessary. The Plan
denied your request. The Plan says an invalid diagnosis code was 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 code 76642 is not supported in the medical record. Specifically, the procedural code billed
included an anatomical modifier noting the service was performed on the left side. The diagnosis code used
does not specify laterality. The claim must include a diagnosis code that matches the laterality of the procedure
code billed. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not
been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76642) provided July 1,
2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for closed treatment of a fracture (27786) provided March 14,
2020.
You asked the Plan to pay for the fracture treatment. You say that the services were medically necessary. The
Plan denied your request. The Plan says services were billed incorrectly.
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 code 27786 is not supported in the medical record. Specifically, in this case the anatomical
modifier billed with the procedure code noted a procedure performed on the right ankle. The diagnosis code
submitted indicates an injury to the left ankle. The procedure modifier on the claim line does not match the
diagnosis code. Based on this information, we decided that Medicare rules for coverage of the fracture
treatment have not been met. Therefore, we decided that the Plan does not have to pay for closed treatment of a
fracture (27786) provided March 14, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran Emergency Room Visit provided August 24, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you received poor quality services and the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $90 copayment for Emergency Care. You have been asked to pay the Medicare allowable amount of $61.32 for the emergency room visit. The emergency room visit falls within the Emergency Care benefit category. In this case, the allowable amount is less than the $90 noted in the plan contract. 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 copayment foran Emergency Room Visit provided August 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that it is unsafe for the enrollee to go home. The Plan denied your request. The Plan says the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy, but it does not support a need for an intensive rehabilitation therapy program. Our physician reviewer also found that there is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided June 1, 2020, to June 8, 2020.
You asked the Plan to pay for the home health services. You say that the services were medically necessary.
The Plan denied your request. The Plan says a corrected claim is required before this claim can be processed.
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 the home health services are not supported in the provided documentation. Specifically, the claim
submitted included an invalid Type of Bill. Based on this information, we decided that Medicare rules for
coverage of the home health services have not been met. Therefore, we decided that the Plan does not have to
pay for home health services provided June 1, 2020, to June 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming (CPT Code 64566).
You asked the Plan to pre-approve the services. You say that the service is necessary and the member needs to have maintenance done once a month to maintain the success from the PTNS treatment. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 services have not been met. The member has been receiving PTNS since 2017 and have received 45 or more treatments. Your request is not a covered benefit because the records show that the member has exceeded the maximum lifetime number of sessions. The Medicare rules states, "The maximum lifetime number of sessions will be 45 total. Subsequent treatment will not be covered." Therefore, we decided that the Plan does not have to pre-approve posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming (CPT Code 64566).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network
provider.
You asked the Plan to pre-approve the medical services. You say that the member has been seeing their current
counselor for over a year and they have established a good rapport and working relationship. The Plan denied
your request. The Plan says there are in-network providers that can render the 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
the medical services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee currently meets the IRF admission criteria. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting have 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 complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the enrollee does require physical therapy and occupational therapy services, but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF due to poor endurance. Our physician reviewer also found that care at the skilled nursing facility level appears to be more appropriate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT Code 64555).
You asked the Plan to pre-approve the services. You say that the procedure is medically necessary. The Plan denied your request. The Plan says the service is not 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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation provided did not support that the member had undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation. Rather, all of the records provided were from their pain management provider. There was no indication that a psychological screening/evaluation had been completed either (as required by the NCD). For all of these reasons the criteria for coverage of a trial of a spinal cord stimulation (SCS) would not have been met. 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 percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (CPT Code 64555).