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

We decided that the Plan does not have to pre-approve the vertiflex superion device placement surgery (22869, 22870)

You asked the Plan to pre-approve the vertiflex superion device placement surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental and 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 the vertiflex superion device placement surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found evidence is lacking for the long-term benefit of the proposed procedure.

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 vertiflex superion device placement surgery have not been met. Specifically, the service is experimental and not medically necessary. Therefore, we decided that the Plan does not have to pre-approve the vertiflex superion device placement surgery (22869, 22870)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271).

You asked the Plan to pre-approve Keytruda. You say that this is medically necessary. The Plan denied your
request. The Plan says this drug is not supported for use with Stivarga.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Keytruda. Our reviewer says that the
requirements for coverage of Keytruda have not been met. Our physician reviewer found the record indicates
that you have metastatic non-small cell lung cancer. You have previously taken Imfinzi, a PD-L1 inhibitor,
following chemoradiation. Your disease progressed while on Imfinzi. Keytruda is not indicated in the presence
of prior progression on a PD-1/PD-L1 inhibitor.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have
to pre-approve Keytruda (J9271).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve block.

You asked the Plan to pre-approve genicular nerve block. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 genicular nerve block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure that is the subject of ongoing clinical trials. Therefore, the request is considered not 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 genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve block.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided on November 12, 2020.
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, specifically, the submitted medical records do not document the presence of an independent trained observer. Based on this information, we decided that Medicare rules for coverage of sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on November 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.

You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says based on
Medicare guidelines, the SNF services you and/or your provider are requesting do 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 in the Medicare rules section 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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, assisted living, long-term 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vascular surgery consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve a vascular surgery consultation to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 vascular surgery consultation 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 the continuation of inpatient mental health care from
June 23, 2021 and forward.
You asked the Plan to pre-approve the continuation of inpatient mental health care from June 23, 2021 and
forward. You say that the continuation of inpatient mental health care from June 23, 2021 and forward is
medically necessary. The Plan denied your request. The Plan says the continuation of inpatient mental health
care from June 23, 2021 and forward is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
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 continuation of inpatient mental
health care from June 23, 2021 and forward. Our reviewer says that the continuation of inpatient mental health
care from June 23, 2021 and forward is not medically necessary. Our physician reviewer found this enrollee did
not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to
herself or others and did not have any auditory or visual hallucinations while being cooperative with treatment.
It did not appear that active treatment was taking place beyond the date in question. It did not appear that the
services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond
the date in question. I am unable to find an individualized treatment plan however the entire chart is not
present. It did appear that the records were supervised and evaluated by a physician. Based upon review of the
records provided the enrollee does not meet the criteria for continued acute inpatient mental health treatment
for the dates in question of June 23, 2021 and forward as this enrollee was not shown to be a danger to herself
or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with
treatment while not showing any threats to safety.
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 continuation of inpatient mental health care from June 23, 2021 and forward
have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of
inpatient mental health care from June 23, 2021 and forward.
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 requested IRF admission is medically necessary. The Plan denied your request. The Plan says you can safely receive the care in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
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 you are in constant pain. The Plan denied your request. The Plan says there is no need for close care by a rehab physician or an interdisciplinary team for rehab care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 you have a past medical history of cerebral palsy, central spinal cord syndrome, neurogenic bladder, hypertension, asthma and recent COVD 19 infection. You are living at home and has weakness. Your medical conditions are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve myocardial perfusion imaging (78452). You say that the enrollee needs this procedure. The Plan denied your request. The Plan says criteria is not met for myocardial perfusion imaging.
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 myocardial perfusion imaging (78452).
Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a history of occasional anginal symptoms and the electrocardiogram does not show any acute abnormalities. The medical record does not indicate that the enrollee has a contraindication to a stress test without cardiac imaging or has a satisfies the criteria for stress test with cardiac imaging. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging (78452) have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on May 13, 2020.
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 the records do 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. We find that HCPCS code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11) 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 pay for drug testing services (HCPCS G0483) provided to the enrollee on May 13, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of right wrist (73221).
You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity of the requested service. The Plan denied your request. The Plan says your hand surgeon has been consulted and does not feel the MRI is needed. The medical necessity criteria for the requested MRI have not been met.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found an MRI of the wrist requested after falling weeks after the surgery. The surgeon recommended no further workup as she was healing well and had good range of motion. X-ray wrist negative for any addressable issues. Therefore, the MRI is not sufficiently supported and will be considered not medically necessary according to the provided documentation. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of right wrist (73221).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ophthalmology services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve ophthalmology services to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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 ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services coded with 99417 provided on February 2, 2021.
You asked the Plan to pay for the services coded with 99417. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99417 is not supported in the medical record. Specifically, 99417 is not a valid code. Based on this information, we decided that Medicare rules for coverage of the services coded with 99417 have not been met. Therefore, we decided that the Plan does not have to pay for the services coded with 99417 provided on February 2, 2021.
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 needs inpatient rehab to maximize his independence. The Plan denied your request. The Plan says the enrollee does not have complex rehab needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 care hospital for weakness and slurred speech and was treated for a transient ischemic attack.
His medical conditions are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehab 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography services coded 77067 provided on February 25, 2021.
You asked the Plan to pay for the screening mammography services. 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 providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 77067 is screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. We find that CPT code 77067 is not supported in the medical record. Specifically, this code was already billed by the same provider for the same date of this. This means that this is a duplicate claim and is not payable.
Based on this information, we decided that Medicare rules for coverage of the screening mammography services have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammography services coded 77067 provided on February 25, 2021.