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

 
We decided that the Plan does not have to pre-approve submucosal ablation of the tongue base with 
radiofrequency (41530) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the enrollee can't tolerate a continuous positive 
airway pressure device. The Plan denied your request. The Plan says that this service is considered 
experimental and 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The enrollee has 
obstructive sleep apnea. The record does not indicate why the standard treatments for the enrollee's condition 
are not medically appropriate for the enrollee. The requested service has not been shown to be safe and 
effective, as defined by Medicare rules, for the enrollee's condition. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve submucosal ablation of the tongue base with radiofrequency (41530) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya.
You asked the Plan to pre-approve Ilumya. You say that the enrollee has failed other therapies. The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ilumya.
Benefits for Ilumya may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the wheelchair provided on August 19, 2021.
You asked the Plan to reimburse you for the wheelchair. You say that you would like reconsideration because it was going to take too long to get a wheelchair from the Plan. The Plan denied your request. The Plan says no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The file also indicates that you self-referred to this provider while there were in-network providers available. Therefore, we decided that the Plan does not have to reimburse you for the wheelchair provided on August 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the X-ray of the chest (71045) provided August 30, 2021. 
 
You asked the Plan to pay for the X-ray of the chest. You say that you would like this claim reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says an appropriate modifier was not 
billed with this claim 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 71045 
is a column II code to column I code 36558. 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 the X-ray of the chest (71045) provided August 30, 2021.
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 the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
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 you are receiving appropriate care at the present acute care hospital.  There are no 
services available at the LTACH that you require that are not available at the health care setting being offered 
by the health plan. 
 
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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the nuclear medicine study of the heart (78452).
You asked the Plan to pre-approve the nuclear medicine study of the heart. You say that this study is medically necessary for the enrollee's medical condition. The Plan denied your request. The Plan says the requested services are not medically necessary based on the standards of care.
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 nuclear medicine study of the heart. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at issue is the medical appropriateness and necessity of carrying out a radionuclide stress test. The patient has a history of coronary artery disease. His electrocardiogram shows an interpretable pattern. There is no evidence provided that would support the need for radionuclide stress testing. In summary, there is insufficient documentation to support the medical necessity for the requested cardiac stress testing in this patient's clinical management.
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 nuclear medicine study of the heart have not been met. Therefore, we decided that the Plan does not have to pre-approve the nuclear medicine study of the heart (78452).
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 you can't leave the hospital without an 
oxygen machine. The Plan denied your request. The Plan says criteria for admission to the LTACH have not 
been met. Your medical needs are being met in the current acute setting. 
 
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 that there is no documentation provided indicating medical necessity for LTACH 
services. You are receiving appropriate care at the present acute care hospital. There are no services available at 
the LTACH that you require 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 your diagnosis 
and condition 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pelvic ultrasound (76856).
You asked the Plan to pre-approve an ultrasound. You say that this service was necessary to determine why you kept bleeding. The Plan denied your request. The Plan says the requested service is 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 an ultrasound. Our reviewer says that the requested pelvic ultrasound is not considered medically reasonable and necessary in this case. Our physician reviewer found a cyst that does not measure greater than 3 centimeters and less than 10 centimeters does not qualify for coverage. The reviewer found that the enrollee's cyst is measuring at 0.06 centimeters and has decreased in size. The reviewer found there is no clinical rationale for the requested pelvic ultrasound. Therefore, the reviewer has determined that the requested ultrasound is not medically reasonable and 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 an ultrasound have not been met. Specifically, the file indicates that the cyst measures less than 3 centimeters. Therefore, we decided that the Plan does not have to pre-approve a pelvic ultrasound (76856).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an interlaminar epidural injection. 
 
You asked the Plan to pre-approve epidural injection. You say that the enrollee had relief and the last injection 
improved pain, function, and quality of life for 6 weeks. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because the record does not show that repeat epidural steroid 
injection at the same anatomical site is reasonable or necessary. 
 
The Plan follows Medicare rules. Medicare rules state that repeat epidural steroid injection may be covered 
under certain circumstances. 
 
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 epidural injection. Our reviewer says 
that the enrollee does not meet the Medicare criteria for this epidural. Our physician reviewer found the 
enrollee did not get 3 months of pain relief from the first injection at this site. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of epidural injection have not been met. Therefore, we decided that the Plan does 
not have to pre-approve an interlaminar epidural injection.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on May 26, 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. The rules say that laboratory shall not report multiple individual CPT 
codes describing the component test results.  
 
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and 
was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the 
laboratory services rendered on May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve membrane graft services. 
 
You asked the Plan to pre-approve the requested services. You say that the membrane wrap would assist in 
expediting the healing process. The Plan denied your request. The Plan says the wound is stable with no size 
measurements. 
 
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 requested services. Our physician 
reviewer found that the enrollee's left foot amputation site is not healing well. There was no mention of plans to 
use skin substitute or membrane wrap products on the left foot amputation site. The records do show specific 
documentation about which wound or which product the provider is requesting. However, the specific product 
requested is not documented. The review has determined that the services at issue in this case is 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve membrane graft services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (onabotulinumtoxinA) for injection. 
 
You asked the Plan to pre-approve the Botox. You say that this is necessary. The Plan denied your request. The 
Plan says it has been confirmed that this biological will not be billed by the physician directly. As such, it 
cannot be covered under Medicare Part B. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Botox (onabotulinumtoxinA) for injection.  
 
Benefits for the Botox may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 the enrollee cannot be adequately cared 
for in his current condition at a skilled nursing facility. The Plan denied your request. The Plan says the 
enrollee is receiving appropriate inpatient acute care. 
 
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 physician 
reviewer found that the enrollee was admitted to the acute care hospital with bilateral lower extremity 
weakness. His hospital course was complicated by enterococcus faecalis bacteremia. Recent reports show the 
enrollee is medically stable for discharge. He does not require services at the LTACH that are not available at 
the acute care hospital where he 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. 
 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that the item is medically necessary. The Plan denied your
request. The Plan says you are not on three or more insulin injections a day and do not require frequent
adjustments to your insulin doses.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have
not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral 
nerve, lumbar or sacral (64628) and each additional vertebral body (64629). 
 
You asked the Plan to pre-approve for an Intracept procedure. You say that the service is medically necessary. 
The Plan denied your request. The Plan says this service is 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 for an Intracept procedure. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found there is insufficient literature to establish the safety and efficacy of the requested 
service for the enrollee's specific clinical condition. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of for an Intracept procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a thermal destruction of intraosseous basivertebral nerve, lumbar or sacral 
(64628) and each additional vertebral body (64629).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology evaluation rendered on May 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 the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 88173 (cytopathology, evaluation of fine needle aspirate) and 88321 (microslide consultation). Code 88173 is a column II code with a modifier indicator of 1 when billed with column I code 88321. Code 88173 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the cytopathology evaluation rendered on May 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for osteogenesis stimulator (E0747) provided on August 27, 2021.
You asked the Plan to pay for osteogenesis stimulator. You say that you believe this item should be paid as you had received authorization. The Plan denied your request. The Plan says this claim has not been billed in accordance with Medicare coding regulations.
The Plan must follow Medicare rules. Medicare rules say that a device coded E0747 must include the KF modifier on the claim line.
We looked at the file and Medicare rules. In this case, the osteogenesis stimulator coded E0747 has not been billed with the KF modifier as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pay for osteogenesis stimulator (E0747) provided on August 27, 2021.