Persius/hicric huggingface dataset:
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 you need IRF care. The Plan denied your request. The Plan says rules for IRF care 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 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 that on review of the available records you have debility from coronavirus pneumonia and are medically stable. With your comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. At the current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While you may benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate and lower intensity setting such as in an skilled nursing facility.  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 pay for a prostate biopsy (55705) provided on June 9, 2021.  You asked the Plan to pay for a prostate biopsy. You say that you did not wish to change doctors in the middle of a critical treatment process. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for a prostate biopsy (55705) provided on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Embrace blood glucose monitor.  You asked the Plan to pre-approve an Embrace blood glucose monitor. You say that the item is medically necessary. The Plan denied your request. The Plan says the member must use a preferred brand.  The Plan follows Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands and manufacturers.relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an Embrace blood glucose monitor. Our reviewer says that the member does not need this item. Our physician reviewer found there is no documentation indicating why the requested brand is medically necessary over the preferred brand.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Embrace blood glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve an Embrace blood glucose monitor.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Reblozyl for the enrollee.  You asked the Plan to pre-approve Reblozyl. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of Reblozyl in the absence of ring sideroblasts have not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Reblozyl. Our reviewer says that Reblozyl is not medically reasonable and necessary. The enrollee has a diagnosis of symptomatic anemia related to myelodysplastic syndrome and chronic kidney disease. The record indicates that the enrollee underwent bone marrow biopsy that did not reveal ringed sideroblasts. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Reblozyl.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Reblozyl have not been met. Therefore, we decided that the Plan does not have to pre-approve Reblozyl for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a MyoPro (L8702).  You asked the Plan to pre-approve a MyoPro. You say that the service is medically necessary. The Plan denied your request. The Plan says this service is experimental.  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 a MyoPro. Our reviewer says that the requested iservices is not considered medically reasonable and necessary in this case. Our physician reviewer found The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in this patient's condition.  There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase  participation in bimanual activities.  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 MyoPro have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro (L8702).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis (72196).  You asked the Plan to pre-approve MRI of the pelvis. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the 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 MRI of the pelvis. Our reviewer says that the requested MRI is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 79-year-old woman who has a diagnosis of monoclonal gammopathy. In this case, the member has none of the red flags identified by the North American Association of Spine Surgeons (NASS) as an indication for advanced imaging for chronic back pain. She has not had physical therapy. X-rays demonstrate degenerative arthritis no compression fractures or other abnormalities noted. The review has determined that the requested MRI of the spine is not medically necessary or reasonable.        We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI of the pelvis have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis (72196).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on April 21, 2021, by an OON
provider.
You asked the Plan to pay for a physician visit. You say that the enrollee's primary care physician referred the
enrollee, and the services were provided. The Plan denied your request. The Plan says the services were not
referred by a 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for a physician visit provided on April 21, 2021, by an
OON provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for analysis of electroencephalogram (EEG) (95957), nerve conduction studies (95908), and needle electromyography (95885) provided on December 28, 2020.  You asked the Plan to pay for EEG analysis 95957, nerve conduction studies 95908, and needle electromyography 95885. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the records do not support these codes.  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 95957 is digital analysis of electroencephalogram (EEG) (for epileptic spike analysis). The CPT Code Manual definition of code 95908 is nerve conduction studies, 3-4 studies.  The CPT Code Manual definition of code 95885 is limited needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude, and latency/velocity study; (listed 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 EEG analysis 95957, nerve conduction studies 95908, and needle electromyography 95885. Our reviewer says that these codes do not meet criteria for payment. Our reviewer found the procedure report does not describe sensors placed on the enrollee's head to measure and record the brain's electrical activity for digital analysis of EEG in cases of epilepsy. The procedure report describes pedicle screw stimulation was performed. Nerve conduction study is an incorrect procedure to report for pedicle screw stimulation as nerve conduction studies are performed with electrodes placed directly over the nerve. Code 95885 describes that it is done with nerve conduction studies. Since the nerve conduction studies are not supported by the procedure report, this procedure would not be covered.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of EEG analysis 95957, nerve conduction studies 95908, and needle electromyography 95885 have not been met. Therefore, we decided that the Plan does not have to pay for analysis of electroencephalogram (EEG) (95957), nerve conduction studies (95908), and needle electromyography (95885) provided on December 28, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that you would like to transfer to the SNF because it is only 5 miles away from home. The Plan denied your request. The Plan says that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.  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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram provided on September 21, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the electrocardiogram. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue weas urgent or emergent. Therefore, we decided that the Plan does not have to pay for the electrocardiogram provided on September 21, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the laboratory services coded as 88342 and billed with the 59-modifier provided on October 13, 2021.  You asked the Plan to pay for the laboratory services as billed. You say that this service has been billed appropriately and should be reprocessed for payment. The Plan denied your request. The Plan says that the code has been billed incorrectly with the -59 modifier.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laboratory services as billed Our reviewer says that the services have been coded correctly in this case. Our physician reviewer found the documentation submitted was reviewed, and the criteria for payment have been met. In this case, the provider reported Current Procedural terminology (CPT) 88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure with modifier 59 in addition to CPT 88344. The laboratory report describes two different specimens and different antibodies. Therefore, this procedure was reported correctly.  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 laboratory services as billed have been met. Therefore, we decided that the Plan has to pay for the laboratory services coded as 88342 and billed with the 59-modifier provided on October 13, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that LTACH care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.  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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 pay for the prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure services coded 99417 provided on September 30, 2021.  You asked the Plan to pay for the prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure 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 99417 is prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services).  We find that CPT code 99417 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure services have not been met. Therefore, we decided that the Plan does not have to pay for the prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure services coded 99417 provided on September 30, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter and angiography services provided on April 30,
2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed
codes cannot be verified.
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 36215 is selective catheter placement, arterial system;
each first order thoracic or brachiocephalic branch, within a vascular family. The CPT Code Manual definition
of code 75710 is Angiography, extremity, unilateral, 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 services provided. Our reviewer found that the procedure
report describes access "Right Radial Cephalic AVF", and advanced to examine arterial inflow. The services at
issue would not be reported separately from CPT 36902.
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 services provided have not been met. Therefore, we decided that the Plan
does not have to pay for the catheter and angiography services provided on April 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee's condition does not meet the Medicare guidelines for care in a LTACH.  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 there is no documentation provided indicating medical necessity for admission to a LTACH.    The enrollee is receiving appropriate care at the present acute care hospital. Our reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 LTACH services.