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

We decided that the Plan has to pre-approve a protective surface cover and stance fluid extension knee component for a transfemoral prosthesis.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that prosthetic additions are covered when specific criteria are 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 services are medically necessary. Our physician reviewer found the enrollee requires a transfemoral prosthesis for mobility and accomplishing her daily activities. She has the capacity to be a K3 level ambulator. She requires a hydraulic knee that can provide mobility at the K3 level and therefore the requested stance fluid extension knee component is required for stability. Additionally, the patient is noted to live on an island with exposure to saltwater and a protective covering is required to protect the components of the prosthesis and extend its life. Therefore, the protective surface cover and stance fluid extension knee component for the enrollee's transfemoral prosthesis are 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 these services have been met. Therefore, we decided that the Plan has to pre-approve a protective surface cover and stance fluid extension knee component for a transfemoral prosthesis.

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 home ventilator.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.

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 services are not medically necessary. Our physician reviewer found the enrollee was recently hospitalized with altered mental status and a urinary tract infection (UTI), with elevated lactate and electrolyte abnormalities. The arterial blood gas (ABG) study was consistent with either acute respiratory acidosis or combined metabolic acidosis and chronic hypercarbic respiratory failure. There is no ABG while stable to confirm chronic carbon dioxide retention. The diagnosis of chronic obstructive pulmonary disease (COPD) is
not confirmed with pulmonary function tests. The home ventilator is not reasonable or medically necessary based on the submitted documentation.

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 a home ventilator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says IRF services are not medically necessary.

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 enrollee's rehabilitation needs can be provided in a lower intensity and alternate 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee clearly meets criteria for a medically appropriate LTACH admission. You say the enrollee is medically complex with multiple acute and chronic conditions that require multidisciplinary care, including daily physician oversight, specialty consults, 24-hour nursing and respiratory care, wound care, and rehabilitation. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services requested do not meet the requirements for approval.

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 has ongoing medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's needs will be met at the LTACH, and they will continue to work on invasive wound care and manage the enrollee's other medical issues confidently. The Plan denied your request. The Plan says based on Medicare guidelines, the LTACH services requested do not meet the requirements for approval.

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 has ongoing medical issues and still requires acute care services before transitioning to a lower level of care. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has multi-level degenerative disease including moderate to severe central stenosis an severe foraminal stenosis. The record does not document that the enrollee is not indicated for surgery at no more than two levels. The Vertiflex spacer is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee's current condition and needs are a priority, and their potential recovery can be met faster in an LTACH. The Plan denied your request. The Plan says the enrollee does not meet the Medicare guidelines for admission 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 does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The Plan has approved ongoing care in the current acute care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has Gleason 8 (4+4) adenocarcinoma. A computed tomography (CT) scan and bone scan were negative for metastatic disease. A review of the current medical literature indicates that moderate hypofractionation external beam radiation therapy is the preferred treatment for high-grade, localized prostate cancer. Stereotactic body radiation therapy can be considered in cases where standard external beam radiation therapy is logistically impossible or poses an undue hardship. The records do not show that conventional external beam radiation therapy is logistically impossible or poses an undue hardship in this case. Also, the records show that Decipher testing indicates low risk for developing metastatic disease and that active surveillance may be preferable. SBRT is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve stereotactic body radiation therapy (SBRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a multi-axial rotation unit and Flex-walk system for a prosthesis.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that prosthetic attachments are covered when specific criteria are 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 services are not medically necessary. Our physician reviewer found the physician progress note does not support that the enrollee is a K3 ambulator. He is noted to be in physical therapy for a contracture. The records do not support that the requested services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a multi-axial rotation unit and Flex-walk system for a prosthesis.
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 the enrollee needs physical therapy and speech therapy that the facility provides. The Plan denied your request. The Plan says the SNF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as part-time skilled services in a long-term care facility.

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 requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does 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: 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 inpatient rehabilitation because you are in pain and cannot use your legs. You say you are a fall risk. The Plan denied your request. The Plan says the IRF care is not medically necessary, and your needs can be met at a lower level of care such as a skilled nursing facility, home with home health services, or home with outpatient therapy.

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 you have chronic functional loss and has no indication for an acute IRF admittance. You do not require intensive rehabilitation and you have no medical or other condition requiring frequent physiatry oversight.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.

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 enrollee is deconditioned after an acute illness and 
has a residual hemiparesis on left. The enrollee does not require intensive or complex  rehabilitation services and does not require frequent physiatry oversight.

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 pay for codes 28730, 28737, 73620, A9270, C1713, C1734, and C1769 provided on June 10, 2022.

You asked the Plan to pay for codes 28730, 28737, 73620, A9270, C1713, C1734, and C1769. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says pass-through device lacks required procedure per Medicare guidelines

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 find that CPT codes 28730, 28737, 73620, A9270, C1713, C1734, and C1769 are not supported in the medical record. Specifically, code C1734 is a pass-through device that must be billed with codes 27870, 28715, 28725, or 28705. The claim was not billed with one of these required procedure codes. This means that claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of codes 28730, 28737, 73620, A9270, C1713, C1734, and C1769 have not been met. Therefore, we decided that the Plan does not have to pay for codes 28730, 28737, 73620, A9270, C1713, C1734, and C1769 provided on June 10, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 provided on May 6, 2022. 
 
You asked the Plan to pay for procedure code J3490. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed is not separately payable. 
 
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 find that CPT code J3490 is not supported in the medical record. Specifically, this service is included in the 
global surgery package of code 20552 which was billed on the same date of service. Based on this information, 
we decided that Medicare rules for coverage of procedure code J3490 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code J3490 provided on May 6, 2022.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code(s) 96361, 96374, 96375, 93005, 
A4649, 70450, 71045 and 73620 billed for date of service August 20, 2022.

You asked the Plan to pay for procedure code(s) 96361, 96374, 96375, 93005, A4649, 70450, 71045 and 
73620. You say that these services were reported correctly and are supported as billed. The Plan 
denied your request. The Plan says these services were not reported in accordance with Medicare 
billing guidelines.

The Plan must follow Medicare rules. Medicare rules say that providers must report services 
correctly. Providers must report services with the appropriate CPT code. Technical components must 
be billed by the facility where the enrollee was an inpatient or outpatient and are not separately 
payable to the lab. The rules also say that payment may not be made for services with a 
Professional/Technical Indicator of 5 when they are provided to hospital inpatients or patients in 
a hospital outpatient department.

The records indicate that these services were provided to the enrollee while an inpatient or 
outpatient. Per the Physician Fee Schedule, there is a Professional/Technical indicator of 1 for 
CPT code(s) 70450, 71045 and 73620. This means there is both a professional and technical component 
for the CPT code(s). In this case, an appropriate modifier to indicate the professional component 
has not been billed with CPT code(s) 70450, 71045 and 73620. In addition, codes 96361, 96374 and 
96375 have a Professional/Technical indicator of 5. This means that these services cannot be paid 
in this case because the record shows that the enrollee was an inpatient or outpatient of a 
hospital at the time of services.

In this case, we have also confirmed that code 93005 is a column II code to column I code 29515. 
This claim has not been billed with an appropriate modifier to bypass the edit. In addition, code 
A4649 has a status indicator of P, which means that no separate payment is made for this service; 
there are no relative value units for this service and no payment amounts. Based on this 
information, we decided that Medicare billing criteria have not been met for these services. 
Therefore, we decided that the Plan does not have to pay for procedure code(s) 96361, 96374, 96375, 
93005, A4649, 70450, 71045 and 73620 billed for date of service August 20,
2022.