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

 We decided that the Plan does not have to pay for the electroencephalogram (95955), needle electromyography (95885) and nerve conduction studies (95908) provided on July 17, 2020.  You asked the Plan to pay for the electroencephalogram, needle electromyography and nerve conduction studies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We 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 electroencephalogram, needle electromyography and nerve conduction studies. Our reviewer says that CPT codes 95955, 95885 and 95908 do not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 95955 is an inappropriate code to report for "real time" monitoring.  Intraoperative Neuromonitoring is a procedure that describes ongoing electrophysiologic testing and monitoring performed during surgical procedures.  It includes only the time spent during an ongoing, concurrent, real-time electrophysiologic monitoring. As the procedure report documents "real-time" monitoring, there is more appropriate code set to report for this procedure.  CPT 95885 is "done with nerve conduction studies".  In this case, pedicle screw stimulation was performed.  Therefore this procedure would not be covered. For CPT 95908, the procedure report describes that "Pedicle screw stimulation" was performed and reported with nerve conduction studies.  This is an incorrect code to report for Pedicle testing, as Nerve conduction studies include measurement of amplitude, latency, and conduction velocity.  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 electroencephalogram, needle electromyography and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the electroencephalogram (95955), needle electromyography (95885) and nerve conduction studies (95908) provided on July 17, 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 you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service 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. Although 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: 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 reasonable and 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 patient was admitted for syncope and was discharged to skilled nursing on December 21, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the flexible protective outer surface covering for a prosthetic leg (L5962).  You asked the Plan to pre-approve the flexible protective outer surface covering. You say that this equipment is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that protective outer surface covering systems (L5962, L5964, and L5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has special needs for protection against unusually harsh environmental situations.  We looked at the file and Medicare rules. In this case, there is no evidence that the enrollee is an unusually harsh environmental that would require this protective outer surface. Based on this information, we decided that Medicare rules for coverage of the flexible protective outer surface covering have not been met. Therefore, we decided that the Plan does not have to pre-approve the flexible protective outer surface covering for a prosthetic leg (L5962).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Pure Wick Urinary System.  You asked the Plan to pre-approve a Pure Wick Urinary System. You say that you used this system in the hospital, and it helped. The Plan denied your request. The Plan says that Medicare states that this is considered an item for comfort and convenience.  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 Pure Wick Urinary System. Our reviewer says that a Pure Wick Urinary System is not considered medically reasonable and necessary in this case. The Pure Wick Urinary System is not considered a standard treatment option for overactive bladder with urinary incontinence. There are no peer-reviewed articles published in the medical literature specific to the PureWick system, or external urinary collection system using a continuous low-pressure pump. Thus, there is no evidence to show the PureWick system to be an effective alternative in managing urinary incontinence. Our physician reviewer found that your 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 a Pure Wick Urinary System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Pure Wick Urinary System.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the injection of daratumumab 10 mg (J9145), provided on January 5, 2021, through February 2, 2021.  You asked the Plan to waive the coinsurance for the injection of daratumumab 10 mg. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.   You have been asked to pay a 20% coinsurance for the injection of daratumumab 10 mg. This service falls within the Medicare Part B prescription drugs benefit category.   This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the injection of daratumumab 10 mg (J9145), provided on January 5, 2021, through February 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care with principal diagnosis code A41.9 with diagnosis related group (DRG) 872 provided from January 7, 2020 to January 16, 2020.
You asked the Plan to pay for the inpatient hospital care with principal diagnosis code A41.9 with DRG 872.
You say that the medical records support the billing of the principal diagnosis code A41.9 with DRG 872. The
Plan denied your request. The Plan says the medical records do not support the billing of the principal
diagnosis code A41.9 with DRG 872.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with A41.9. 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 inpatient hospital care with principal diagnosis code A41.9 with DRG 872.
Our reviewer says that the medical records do not support the billing of the principal diagnosis code A41.9 with
DRG 872. Our physician reviewer found based on the medical records provided the diagnosis of cellulitis
(rather than sepsis) more accurately describes the enrollee's condition and treatment during the hospitalization
in question. Records did not document hypotension, the need for vasopressors, objective fever, sustained
tachypnea or tachycardia or significant renal, cardiac, pulmonary or hepatic dysfunction that was directly
related to the cellulitis/infection. Blood and urine cultures showed no growth. By January 12, 2020 medical
notes were reporting that the sepsis was resolved; the enrollee remained inpatient through January 16, 2020.
The principal diagnosis of cellulitis more accurately represents the enrollee's condition and treatment during
this hospitalization.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital care with principal diagnosis code A41.9 with diagnosis related group (DRG) 872
provided from January 7, 2020 to January 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint injections.  You asked the Plan to pre-approve facet joint injections. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary for patients who meet specific criteria.  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 facet joint injections. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record provided is insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for urography (74420) provided on July 13, 2021.  You asked the Plan to pay for urography. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this is a bilateral code that should only be reported once, so this is a duplicate charge.  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 74420 is urography, retrograde, with or without KUB.  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 urography.   Our reviewer says that this code does not meet criteria for payment. Our reviewer found the records submitted do not include any documentation to support this procedure.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of urography have not been met. Therefore, we decided that the Plan does not have to pay for urography (74420) provided on July 13, 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 the level of care provided in an IRF. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the necessary services in an alternate setting.  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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you would benefit from SNF care and your family is unable to perform wound care. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  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 do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  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 skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve complete lower dentures (D5120), and complete upper dentures (D5110).  You asked the Plan to pre-approve complete lower dentures, and complete upper dentures. You say that the services are necessary. The Plan denied your request. The Plan says the services are covered benefits, but you have exceeded the frequency limit of once every 5 years.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of complete lower dentures, and complete upper dentures have not been met. Specifically, the record shows that you had exceeded the frequency limit for these services on October 7, 2020. Therefore, we decided that the Plan does not have to pre-approve complete lower dentures (D5120), and complete upper dentures (D5110).
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 enrollee needs inpatient physical therapy. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in a lower level of care, such as a skilled nursing facility.  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 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve transcatheter aortic valve replacement (TAVR) for the enrollee.  You asked the Plan to pre-approve these services. You say that the member has a progressive shortness of breath with minimal exertion and has signs/symptoms of heart failure including adverse remodeling of her left ventricle. The Plan denied your request. The Plan says that the enrollee does not have aortic stenosis.  The Plan must follow Medicare rules. Medicare rules say that TAVR can be covered if Medicare criteria have been met.  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 documentation supports the presence of severe aortic regurgitation, but not aortic stenosis. Guidelines would not support the use of TAVR for this indication for a number of reasons, including the lack of aortic valve calcification in many such patients which can make anchoring of the new valve challenging. While there have been several promising clinical studies, there remain calls for continued clinical trials to assess the efficacy of TAVR for aortic regurgitation. Until such statistically rigorous studies are completed, it is premature to presume clinical outcomes and benefit. Our physician reviewer found that the enrollee's condition does not meet Medicare 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 transcatheter aortic valve replacement (TAVR) for the enrollee.