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

We decided that the Plan does not have to pay for a radiofrequency ablation of genicular nerves (64624) provided on December 28, 2020.

You asked the Plan to pay for a radiofrequency ablation of genicular nerves. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the service at issue is experimental/investigational.

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 pay for a radiofrequency ablation of genicular nerves. Our reviewer says that the services at issue are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has bilateral knee osteoarthritis presenting with bilateral knee pain. Genicular nerve blocks and genicular nerve radiofrequency ablation are considered investigational and not medically necessary for the treatment of chronic knee pain, including but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery.

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 radiofrequency ablation of genicular nerves have not been met. Therefore, we decided that the Plan does not have to pay for a radiofrequency ablation of genicular nerves (64624) provided on December 28, 2020.
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 admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
does not require at least 3 hours a day /5 day a week, or 15 hours over 7 consecutive days, of therapy services. 
While the enrollee may be able to fully participate in an intensive rehabilitation therapy program, the 
documentation supports that the needed services can be provided 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: Surgery
Decision: Favorable

 We decided that the Plan has to pay for a complex repair of the trunk (13101) and 3 units of a complex repair of the trunk for each 5 additional centimeters (13102) provided on September 10, 2021.  You asked the Plan to pay for a complex repair of the trunk and 3 units of additional repair. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says that the codes at issue are part of another billed code.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also 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 a complex repair of the trunk and 3 units of additional repair. Our reviewer says that the billed codes meet criteria for payment. Our physician reviewer found that the procedure report documents one wound measuring 30 by 15 centimeters. The wound was treated with two different closures in different areas of the wound. The provider clearly documented the reason why this wound required this closure technique. The provider is reporting 418 square centimeters for complex closure. The majority of the wound was closed with complex closure. The closure is reported by length per CPT guidelines. In this case the wound was 30 centimeters in length and 22 centimeters would be reported for the complex closure. Therefore 1 unit 13101 and 3 units 13102 meet criteria for payment.  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 complex repair of the trunk and 3 units of additional repair have been met. Therefore, we decided that the Plan has to pay for a complex repair of the trunk (13101) and 3 units of a complex repair of the trunk for each 5 additional centimeters (13102) provided on September 10, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex procedure. 
 
You asked the Plan to pre-approve the Vertiflex procedure. You say that this is medically reasonable and 
necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is 
considered experimental/investigational. 
 
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 procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the Vertiflex device is experimental. More research is needed. 
 
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 procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex procedure.
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 this is medically necessary. The Plan denied your request. The Plan says the requested LTACH services are not medically necessary, reasonable, or appropriate for the diagnosis and condition of the enrollee at this time.  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 appears to be improving overall, but requires short-term additional acute care services that can safely be completed at the current facility until more stable. The enrollee does not require services at the LTACH that are not already available at the current facility. Transfer to LTACH is not medically necessary as it would not be clinically advantageous. Transfer may be considered when treatment has completed and when the enrollee is more stable.    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 the Plan does not have to pay for medical services billed under code 99291. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was 
performed on the billed date of service. The documentation does not include the time spent providing this 
service; therefore, the billed Critical Care Evaluation and Management code cannot be verified. It is noted that 
multiple attempts were made to contact the provider for additional information. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate codes and when necessary, provide the documentation to 
support the services billed. In this case, the medical records provided do not have the required time 
documentation for the services billed. Medicare billing criteria are not met. Therefore, we decided that the Plan 
does not have to pay for medical services provided to the enrollee on August 10, 2021 and billed under code 
99291.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Privigen and Ruxience.  You asked the Plan to pre-approve Privigen and Ruxience. You say that the records provided support the medical necessity of the drugs in dispute. You say that, without the requested treatment, the enrollee may ultimately develop antibody mediated rejection. The Plan denied your request. The Plan says there is no reason that the enrollee cannot use a preferred agent.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Privigen and Ruxience. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found there is no documentation on why these agents are to be used over bio-similar agents that are approved for use by the insurer.  These requested agents are only approved as part of step therapy where the approved drugs are not tolerated or effective.  There is no documentation of this being the 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 Privigen and Ruxience have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen and Ruxience.
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 are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF care 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 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. While the enrollee may require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. There is not a reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravitreal injection rendered on July 13, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that bilateral surgeries must be billed with modifier -
50. 
 
We looked at the file and Medicare rules. The file shows that code 67028 was not billed with the required 
modifier -50. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the intravitreal injection rendered on 
July 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you are a 75-year-old female with a medical
history including endometrial cancer, diabetes mellitus and gastroesophageal reflux disease who was admitted
to an acute hospital with abdominal pain. The medical record is reviewed in its entirety. The member has not
stabilized medically. Further rehab services would be appropriate to improve function when she has stabilized.
Until then she can continue to receive services at the acute care hospital. Admission to a SNF for inpatient
skilled rehab services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional home health skilled nursing visits.

You asked the Plan to pre-approve home health skilled nursing services. You say that home health services are medically necessary. The Plan denied your request. The Plan says rules for home health skilled nursing services have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health skilled nursing services. Our reviewer says that home health skilled nursing services are not medically reasonable and necessary. Our physician reviewer found the documentation doesn't support that the member requires additional skilled nursing services to provide treatment that is medically necessary. The member does not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are 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 home health skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional home health skilled nursing visits.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing rendered on January 28, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 95885 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).  We find that CPT code 95885 is not supported in the medical record. Specifically, there is no documentation of a limited needle electromyography, per each extremity, with related paraspinal areas when performed, with nerve conduction, amplitude, and latency/velocity study. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing rendered on January 28, 2021.
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 that you are an 85-year-old woman who was admitted to the hospital on February 20, 2022, with bilateral subdural hematomas. You underwent surgery with placement of bilateral burr holes. The post-operative course was complicated by atrial fibrillation. The documentation does not support that the complexity of your nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require at least 3 hours a day /5 days a week, or 15 hours over 7 consecutive days, of therapy services. While you may well be able to fully participate in an intensive rehabilitation therapy program, the services may be provided 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided to the enrollee on April 20, 2021 
and billed under codes 95885, 95908, and 95955. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says based on the medical records provided, the documentation does not substantiate or 
properly describe the services billed. The Plan states there are more appropriate codes that can be used for the 
services provided and/or billed. 
 The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. The records provided do not support the codes billed based on their 
descriptions and the documentation required in the medical records. Medicare billing criteria are not met. 
Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on 
April 20, 2021 and billed under codes 95885, 95908, and 95955.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for flow cytometry services (procedure code 88189) provided to 
the enrollee on September 22, 2021. 
 
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 claim was billed with a manifestation diagnosis code as the primary diagnosis. 
 
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 88189 is "Flow cytometry, interpretation; 16 or more 
markers." 
 
We find that CPT code 88189 is not supported in the medical record. Specifically, it is not appropriate coding 
to have a manifestation diagnosis used a primary diagnosis. 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 flow cytometry services (procedure code 88189) provided to the enrollee on September 22, 
2021.