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

We decided that the Plan does not have to pre-approve bronchial thermoplasty. 
 
You asked the Plan to pre-approve the procedure. You say that this is needed to hopefully reduce the amount of 
medication to prevent further medical problems like avascular necrosis. The Plan denied your request. The Plan 
says the current role for this service remains uncertain. 
 
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 procedure. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have a diagnosis of severe asthma and are on maximum medical treatment. You are having 
frequent exacerbations of symptoms requiring bursts of steroids. His clinical characteristics do not meet the 
requirements for this request. Specifically, you are having more than four exacerbations per year requiring 
steroids, and your smoking history (16 pack years) is greater than 10 pack years. The medical records do not 
include pulmonary function tests. In addition, questions remain about the clinical benefits versus risks of 
bronchial thermoplasty in the treatment of severe asthma. 
 
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 procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve bronchial thermoplasty.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
You asked the Plan to pre-approve the wheelchair ramp. You say that the wheelchair ramp is medically necessary. The Plan denied your request. The Plan says the wheelchair ramp is not a covered item.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on May 17, 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 May 17, 2021 by an out-of-network (OON) provider
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.
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 the service is medically necessary. Our physician reviewer found daily skilled services are required to establish a maintenance program and/or to prevent deterioration of your 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous stabilization device.
You asked the Plan to pre-approve the requested device. You say that the enrollee has tried at least six months of conservative care without relief of symptoms. The Plan denied your request. The Plan says unproven procedures are not covered by Medicare.
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 device. Our physician reviewer found that in this case, the record indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The imaging demonstrates multi-level disease, including severe spinal stenosis at L3-L4, one of the levels requested for treatment. The record does not state that the enrollee is not indicated for operative therapy at no more than two levels. There is no assessment of whether the enrollee has osteoporosis. The elements of the coverage criteria are not satisfied. Therefore, the requested services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an interspinous stabilization device
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a biventricular pacemaker. 
 
You asked the Plan to pre-approve the insertion of a biventricular pacemaker. You say that this request is 
medically necessary. The Plan denied your request. The Plan says the insertion of a biventricular pacemaker 
and related services is not medically 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 insertion of a biventricular 
pacemaker. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found that the patient has a mild depression of ejection fracture 
(EF) on echo and symptoms of dyspnea but also has significant chronic obstructive pulmonary disease (COPD) 
and is on oxygen therapy. He is only on low dose medications for congestive heart failure (CHF) including beta 
blocker and SGlt2 inhibitor. He has sick sinus syndrome with a well-functioning DDD pacemaker. The burden 
of atrial fibrillation (AF) is less than 1% and ventricular pacing is also <1% at present. His electrocardiogram 
shows an intraventricular conduction delay (IVCD) but not a left bundle branch block (LBBB) pattern. 
Although he has dyspnea, he does not meet any of the current criteria for a biventricular pacing device. His EF 
is not <35%, his IVCD is <0.15 msec and is not in a LBBB pattern. In addition, he is ventricular paced <1% of 
the time and he relies mainly on atrial pacing only based on the most recent pacer interrogation data. Therefore, 
based on current guidelines he does not meet any published indication for biventricular pacing at the current 
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 insertion of a biventricular pacemaker have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the insertion of a biventricular pacemaker.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repeat radiofrequency ablation services.
You asked the Plan to pre-approve repeat radiofrequency ablation services. You say that this procedure is medically reasonable and necessary. The Plan denied your request. The Plan says that the requested procedure does not meet Medicare coverage criteria.
The Plan follows Medicare rules. Medicare rules say that repeat radiofrequency ablation services 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 repeat radiofrequency ablation services. Our reviewer says that the requested repeat radiofrequency ablation services are medically reasonable and necessary. Our physician reviewer found this 78-year-old woman has posterior thoracic pain. She is post T7 and T8 compression fractures which were treated with kyphoplasty. She had radiofrequency ablation of T11 and T12 in 2017 and 2021 which produced long lasting relief. Diagnostic blocks do not need to be repeated after successful RFA. The request is 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 repeat radiofrequency ablation services have been met. Therefore, we decided that the Plan has to pre-approve repeat radiofrequency ablation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids, provided on June 14, 2021.
You asked the Plan to pay for the hearing aids. You say that the item is medically necessary. The Plan denied your request. The Plan says you have exhausted your Plan's maximum benefit for this service.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for up to a $1,000 allowance for up to two hearing aids every two calendar years. We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids, provided on June 14, 2021.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Nulojix for the enrollee.
You asked the Plan to pre-approve Nulojix. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that the drug 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 FDA-approved 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 Nulojix. Our reviewer says that Nulojix is medically reasonable and necessary for the enrollee. There is sufficient data on the use of Nulojix for prevention of organ transplant rejection. This patient has nephrotoxicity from the sirolimus and Nulojix is being used appropriately as salvage therapy. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Nulojix. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix have been met. Therefore, we decided that the Plan has to pre-approve Nulojix for the enrollee.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the five home skilled nursing visits (G0299).
You asked the Plan to pre-approve the five home skilled nursing visits. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.
A doctor must certify the need for home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the five home skilled nursing visits. Our reviewer says that the service is not medically necessary. Our physician reviewer found you do not have any documented skilled nursing needs. 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 five home skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the five home skilled nursing visits (G0299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and a powered pressure-reducing air mattress (E0277).
You asked the Plan to pre-approve a semi-electric hospital bed and a powered pressure-reducing air mattress. You say that the enrollee needs these items. The Plan denied your request. The Plan says the enrollee has a hospital bed and does not meet the criteria for a pressure-reducing air mattress.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The rules also say that a group 2 support surface is covered if the beneficiary has multiple stage 2 pressure ulcers located on the trunk or pelvis or had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days. The file shows that the enrollee currently has a semi-electric hospital bed. The record does not show that the enrollee multiple stage 2 pressure ulcers located on the trunk or pelvis or had a myocutaneous flap or skin graft
for a pressure ulcer on the trunk or pelvis within the past 60 days. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and a powered pressure-reducing air mattress (E0277)
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the nine home skilled nursing visits (G0299).
You asked the Plan to pre-approve the nine home skilled nursing visits. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the nine home skilled nursing visits. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee does not have any documented skilled nursing needs. 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 nine home skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve the nine home skilled nursing visits (G0299).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the autonomic nervous system function testing and therapeutic procedures provided on February 12, 2020.
You asked the Plan to pay for the autonomic nervous system function testing and therapeutic procedures. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95921 is testing of autonomic nervous system function; cardiovagal innervation (parasympathetic function), including 2 or more of the following: heart rate response to deep breathing with recorded R-R interval, Valsalva ratio, and 30:15 ratio.
The CPT Code Manual definition of code 95923 is testing of autonomic nervous system function; sudomotor, including 1 or more of the following: quantitative sudomotor axon reflex test (QSART), silastic sweat imprint, thermoregulatory sweat test, and changes in sympathetic skin potential. The CPT Code Manual definition of code 97112 is therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.
The CPT Code Manual definition of code 95943 is simultaneous, independent, quantitative measures of both parasympathetic function and sympathetic function, based on time-frequency analysis of heart rate variability concurrent with time-frequency analysis of continuous respiratory activity, with mean heart rate and blood pressure measures, during rest, paced (deep) breathing, Valsalva maneuvers, and head-up postural change
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 autonomic nervous system function testing and therapeutic procedures. Our reviewer says that for CPT codes 95921 and 95923, the procedure report does not document the testing of autonomic nervous system function and the procedures cannot be confirmed as performed. Our reviewer found that for CPT code 97112; the procedure report documents a total of 50 minutes including a setup of 15 minutes. Our reviewer says that the 4 units billed are not supported by the documentation.
In this case, we have confirmed that code 95943 is a column II code to column I code 95921. 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.
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 autonomic nervous system function testing and therapeutic procedures have not been met. Therefore, we decided that the Plan does not have to pay for the autonomic nervous system function testing and therapeutic procedures provided on February 12, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the SelectMDx genetic testing provided on March 26, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this testing is used to help distinguish patients at 
increased risk for clinically significant prostate cancer from those at very low risk for aggressive disease. The 
Plan denied your request. The Plan says that the denial of payment for this testing is correct, because screening 
services without a valid medical diagnosis related to the health of the enrollee are not a benefit. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
This testing was ordered by an in-network provider, who attested to the medical necessity and non-screening 
purpose of this testing. The file does not show that the plan provided notice that the genetic testing would not 
be covered. Under Medicare rules, this means the genetic testing is considered approved by the plan. Therefore, 
we decided that the Plan has to pay for the SelectMDx genetic testing provided on March 26, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81317, 81404, 81405, 81406, 81407, 
81162, 81435, 81479, 81403, 81308, and 81437) provided on April 9, 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 for codes 81317, 81435, 81403, and 81308. The records show that the 
specimen was obtained in an office setting. 
 
We find that codes 81404, 81405, 81406, 81407, 81408, 81162, 81435, 81479, 81437 are not supported in the 
medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. 
Therefore, we decided that the Plan does not have to pay for the laboratory services (81317, 81404, 81405, 
81406, 81407, 81162, 81435, 81479, 81403, 81308, and 81437) provided on April 9, 2021.