Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of impacted ear wax (69210) provided on April 7, 2021.  You asked the Plan to pay for code 69210. 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 claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 69210 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 69210 have not been met. Therefore, we decided that the Plan does not have to pay for the removal of impacted ear wax (69210) provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve prosthesis with computerized knee and advanced foot for the enrollee.  You asked the Plan to pre-approve prosthesis with computerized knee and advanced foot. You say that prosthesis with computerized knee and advanced foot are medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  The Plan must follow Medicare rules. Medicare has specific coverage criteria for a lower limb prothesis. 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 prosthesis with computerized knee and advanced foot. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee meets Local Coverage Determination criteria for the requested prosthesis with computerized knee and advanced foot. Records indicate the enrollee was using a rolling walker to assist with ambulation prior to the right lower extremity amputation - a functional level not consistent with a K3 level. No medical records were provided to this reviewer from a provider who did not have a financial interest in the outcome of the decision which documented necessity of the computerized knee and advanced foot. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of prosthesis with computerized knee and advanced foot have not been met. Therefore, we decided that the Plan does not have to pre-approve prosthesis with computerized knee and advanced foot for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a power mobility device (K0108, K0823).  You asked the Plan to pre-approve the power mobility device. You say that the power mobility device is medically necessary. The Plan denied your request. The Plan says the record shows the enrollee's need for the power mobility device is for community use outside the home. The record shows the enrollee is mobility independent in the home.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power mobility device (K0108, K0823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0675).  You asked the Plan to pay for a pneumatic compression device. 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.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0675).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Yervoy for the enrollee.  You asked the Plan to pre-approve Yervoy. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not being prescribed for a medically-accepted indication.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Yervoy. Our reviewer says that Yervoy is not medically reasonable and necessary for the enrollee. Yervoy is not FDA-approved for the enrollee's diagnosis. Yervoy is FDA approved in combination with Opdivo for 1st line treatment and this patient has had several prior lines of treatment. The use of Yervoy is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services approved medical journal. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Yervoy.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Yervoy have not been met. Therefore, we decided that the Plan does not have to pre-approve Yervoy for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pre-approve a kidney transplant evaluation service.  You asked the Plan to pre-approve a kidney transplant evaluation service. You say that the requested service is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that based on the enrollee's current BMI, it is not medically reasonable and necessary for a kidney transplant evaluation service to be completed at this time.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a kidney transplant evaluation service. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found most transplant centers require a body mass index (BMI) under 40 for transplant, some with transplant with BMI of 45. Regardless, it is reasonable to expect BMI to get under 40 and for transplant evaluation to be initiated. Transplant evaluation for this patient would be considered within the norms of standard of care of many transplant centers and is reasonable and indicated.  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 kidney transplant evaluation service have been met. Therefore, we decided that the Plan has to pre-approve a kidney transplant evaluation service.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed.  You asked the Plan to pre-approve a total electric hospital bed. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says this item is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided from May 19, 2021 to May 26, 2021.  You asked the Plan to pay for the home health 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. Home health care services must be billed on a UB-04 form per Medicare guidelines. The case file shows the home health services were submitted incorrectly. Therefore, we decided that the Plan does not have to pay for the home health services provided from May 19, 2021 to May 26, 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 best course of treatment for the enrollee is to admit him to the LTACH setting where he can be closely monitored by a team of physicians on a daily basis. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to an LTACH.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and should only require short term additional acute care hospital that can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to LTACH will be considered not medically necessary due to there being no clinical advantage. Transfer to a lower level of care may be considered when treatment has completed.  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: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that that you have used your 100 days of SNF services.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any documentation confirming the dates you have had SNF services provided by the Plan. Without this information we are unable to substantiate the Plan's denial and confirm that you have already used 100 days of SNF services. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services.
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: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942-LT-26) and iPACK block (64999) provided on April 12, 2021.  You asked the Plan to pay for codes 76942 and 64999. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  We find that 2 units of CPT code 76942 are supported in the medical record. Based on this information, we decided that Medicare rules for coverage of code 76942 have been met.  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 64999 is Unlisted procedure, nervous system. Currently, there is no specific CPT code to report an iPACK block. Therefore, code 64999, Unlisted procedure, nervous system, should be reported. Based on this information, we decided that Medicare rules for coverage of code 64999 have been met.   Therefore, we decided that the Plan has to pay for the ultrasonic guidance for needle placement (76942-LT-26) and iPACK block (64999) provided on April 12, 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: 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 the SNF admission. You say that you feel that you need to be cared for in a SNF due to your recent surgery. The Plan denied your request. The Plan says you do not meet Medicare SNF criteria as you do not require daily skilled care.  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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a male who was treated in the hospital with a triple coronary artery bypass graft (CABG) procedure. He is currently requiring sternal precautions and has new onset atrial fibrillation managed with oral amiodarone. Recent imaging is negative for stroke. On 11/29/21, the patient was ambulating 400 feet with contact guard assistance with frequent rest breaks for breathing/desaturation. The patient requires standby assistance for transfers and moderate assist for bed mobility.  Based on the records provided, there are no identifiable skilled nursing services required. The documentation supports that skilled therapy services are medically reasonable and necessary for this enrollee, but not on a daily basis and not on an inpatient basis in a skilled nursing facility 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 the SNF admission 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device in spine 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 the device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve flex walk system, all lower extremity prostheses (L5981) multi-axial rotation unit, all lower extremity prostheses (L5986).  You asked the Plan to pre-approve the advanced foot and ankle feature. You say that you require a prosthetic leg to move freely. You have been waiting since 7/03/2021 to get your new leg then you received a denial. The Plan denied your request. The Plan says the request for K3 foot does not meet criteria as reasonable and 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 the advanced foot and ankle feature. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's current prosthesis is a K2 and was reported to be ill-fitting causing a non-healing lesion. The provided records did not clearly show the enrollee as being at a K3 level of activity to justify the K3 prosthesis with the advanced foot and ankle components. Therefore, this request will be considered not medically necessary as submitted.  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 advanced foot and ankle feature have not been met. Therefore, we decided that the Plan does not have to pre-approve flex walk system, all lower extremity prostheses (L5981) multi-axial rotation unit, all lower extremity prostheses (L5986).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician services provided on June 29, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the physician services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the physician services provided on June 29, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (95941) provided on April 13, 2021.  You asked the Plan to pay for code 95941. 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, CPT code 95941 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (95941) provided on April 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer 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 investigational services are not medically reasonable or 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 the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that this 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex interspinous spacer for the enrollee.