Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories (K0862, 
E1007, E2377, E2311) for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says there is no qualifying diagnosis causing a mobility limitation for which a group 3 power 
wheelchair would be medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 services are not medically reasonable or necessary. Our physician reviewer found the enrollee does 
not have a neurologic disorder with resulting functional deficits. He may meet criteria for the use of a power 
mobility device, but not a group 3 power wheelchair. Furthermore, the documentation does not indicate that the enrollee has any pressure injuries or requires 
intermittent catheterization of the bladder. 
 
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 a group 3 power wheelchair and accessories (K0862, E1007, E2377, E2311) for the 
enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 19, 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 provider did not bill as required by Medicare coding regulations.

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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on October 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 29, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 29, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the 
enrollee. 
 
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied 
your request. The Plan says care needs can be adequately addressed with intermittent skilled services and better 
managed in a less restrictive 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 the admission. Our reviewer says that 
the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee 
has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled 
nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab 
services at a lower level of care.  Although further rehabilitation services would be appropriate to improve 
function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a 
skilled nursing facility.  The enrollee does not have any parental medication; complex wound care or nutrition 
given via a feeding tube. She is medically stable without any acute exacerbations of chronic medical 
problems. Her physical function is at or near her baseline and she can receive services at a lower level of 
care.  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 the admission have not been met. Therefore, we decided that the Plan does not 
have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 30, 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 a modifier was not billed on the claim to represent the services as separate/distinct.

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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 30, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa (J7323). 
 
You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says step therapy criteria have not been met. 
 
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 Euflexxa. Our reviewer says that this 
drug is not medically necessary and reasonable for the enrollee's condition. Our physician reviewer found the 
Plan requires a trial of Orthovisc or Supartz FX before they will approve the requested drug. In this case, the 
patient has not tried and failed the required drug(s). There is no documentation provided indicating that the 
plans required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa (J7323).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve the Intracept procedure. You say that this procedure is medically necessary for the enrollee's medical 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 Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is a 64-year-old woman who has moderate to severe degenerative disc disease with spondylosis without myelopathy or radiculopathy in the lumbosacral region. Heat, ice, lumbar epidural steroid injection, pain medication, physical therapy, a transcutaneous electrical nerve stimulation unit, and chiropractic treatments were partially effective. The Intracept procedure is a system for intraosseous nerve ablation. The evidence regarding the efficacy of the Intracept ablation procedure is inconclusive. Current medical literature suggests that the Intracept procedure remains investigational 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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder arthroscopy services provided to the enrollee on July 2, 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 denied codes remain 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 the denied codes is:

CPT 29821: 

Arthroscopy, shoulder, surgical; synovectomy, complete 

CPT 29823:

Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])

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. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found CPT 29821 should only be reported when the underlying diagnosis is pathologic synovium such as is found in rheumatoid arthritis or pigmented villonodular synovitis. Cleaning up the "whole" joint due to reactive synovitis is inclusive of the more extensie codes. In terms of CPT 29823, the operative report documents a complete supraspinatus debridement. This does not support 3 or more discrete structures, and therefore cannot be confirmed.

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 have not been met. Therefore, we decided that the Plan does not have to pay for shoulder arthroscopy services provided to the enrollee on July 2, 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 IRF care is medically necessary for the enrollee's condition. 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 the enrollee with left humerus fracture is medically stable. He does 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. An uncomplicated upper extremity fracture does 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. He needs routine physical therapy and occupational therapy in a lower intensity level. IRF admission is not medically necessary based on lack of medical complexity, and lack of nursing needs. While the enrollee may benefit from physical therapy and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in an SNF.

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 inpatient rehabilitation facility (IRF) services to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve OON IRF care. You say that the condition you are in requires treatment from someone who specializes in spinal cords. The Plan denied your request. The Plan says the services needed can be provided in-network.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 

We looked at the file and Medicare rules. The records show that the Plan has an in-network IRF that has an available open bed in a spinal cord injury unit for the enrollee. This in-network provider is also closer to the enrollee's home address than the requested OON facility. Based on this information, we decided that Medicare rules for coverage of OON IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient rehabilitation facility (IRF) 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 pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve an office visit. You say that this office visit is medically necessary. The Plan 
denied your request. The Plan says there are multiple in-network providers able to provide for the enrollee's 
medical needs. 
 
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 
an office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injection services.

You asked the Plan to pre-approve therapeutic facet joint injection services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage for the injection services have not been met.

The Plan follows Medicare rules. Medicare rules say that the therapeutic facet joint injections are subject to the criteria listed 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 therapeutic facet joint injection services. Our reviewer says that the requested therapeutic facet joint injection services are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-year-old woman who has chronic low back pain from lumbar spondylosis. She is status post Right L3-L4 and L5-S1 radiofrequency ablation of the Medial branches. Request is made for intra-articular Right L3-L4 and L5-S1 steroid injections. The request indicates that the radiofrequency ablation was not successful and therefore other pain generators should be sought. The request is not medically reasonable or necessary 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 therapeutic facet joint injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injection services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (procedure code 99307) 
provided to the enrollee on September 16, 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 this claim does not meet coding standards. 
 
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 99307 is Subsequent Nursing Facility Care. 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the documentation submitted did not 
include an evaluation and management service, as well as, wound care documentation confirm services. The 
documentation does consist of a prior review, stating wound care was the primary reason for services 
performed, and evaluation and management services do not document a distinct service from the debridement. 
 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for subsequent nursing facility care (procedure code 99307) provided to the enrollee on September 
16, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.

You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not meet criteria.

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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not need intravenous medications or complex wound care. You are walking household distances with contact guard assistance. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the assisted living facility with home health care or in a long-term care facility on a part time basis appear 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for lab services (80305) provided to the enrollee on August 12, 2021.

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 additional medical records were not submitted to support the services 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 medical records provided have insufficient information in the record to determine if Medicare rules for coverage of lab services (80305) provided to the enrollee on August 12, 2021. have not been met. medical records to support the claim billed. Therefore, we decided that the Plan does not have to pay for lab services (80305) provided to the enrollee on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on June 4, 2021. 
 
You asked the Plan to pay for the services. You say that this is a valid procedure. The Plan denied your request. 
The Plan says the claim was billed with a manifestation diagnosis 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 00790 is "Anesthesia for intraperitoneal procedures in 
upper abdomen including laparoscopy; not otherwise specified." 
 
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. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the provider reported CPT 00790 with 
a diagnosis of ICD-10 K82.A1 - gangrene of gallbladder in cholecystitis. Coding should always be done to the 
highest specificity. Therefore, ICD 10 K82.A1 has further instruction to "Code first the type of 
cholecystitisK81.-), or cholelithiasis with cholecystitis (K80.00 - K80.19, K80.40 - K80.47, K80..60 - K80.67). 
The services were incorrectly reported. 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 have not been met. Therefore, we decided that the Plan does not 
have to pay for anesthesia services provided to the enrollee on June 4, 2021.