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

We decided that the Plan does not have to pre-approve the advanced foot, rotational unit, vacuum socket and extra protective cover.
You asked the Plan to pre-approve the advanced foot, rotational unit, vacuum socket and extra protective cover. You say that you would like reconsideration because the requested prostheses are medically necessary. The Plan denied your request. The Plan says a prosthetic leg with a foot that is used for a lower activity level may meet your needs.
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, rotational unit, vacuum socket and extra protective cover. Our reviewer says that the extra protective cover is not medically necessary as the treating nurse practitioner progress notes do not support that the member exposed to harsh
environmental conditions beyond the level of protection provided by the patient's approved L5704 protective cover. Our physician reviewer found the advanced foot, rotational unit and vacuum socket exceed the member's need. The treating nurse practitioner notes do not support that the patient is a K3 ambulator. The treating nurse practitioner notes state the member relies on wheeled mobility, has limited mobility, difficulty getting dressed bathing, running errands and walking. 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, rotational unit, vacuum socket and extra protective cover have not been met. Therefore, we decided that the Plan does not have to pre-approve the advanced foot, rotational unit, vacuum socket and extra protective cover.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing services (G0483) provided on June 6, 2021.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that the documentation submitted does not
support that 22 drug classes were tested.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual
drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited
to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g.,
ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if
performed
We find that CPT code G0483 is supported in the record. Specifically, the lab report clearly indicates that 22 or
more drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the
drug testing services have been met. Therefore, we decided that the Plan has to pay for the drug testing services
(G0483) provided on June 6, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pain pump for the enrollee.
You asked the Plan to pre-approve the pump. You say that this is medically necessary. The Plan denied your request. The Plan says the pain pump is contraindicated with the planned continued use of the spinal stimulator.
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 pump. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered the wrong coding (Current Procedural Terminology 62323) for a pump. Additionally, the coverage criteria specifically excludes patients with a spinal cord stimulator in place. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the pump have not been met. Therefore, we decided that the Plan does not have to pre-approve a pain pump for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for additional outpatient PT visits.

You asked the Plan to pay for additional outpatient PT visits. The Plan denied your request. The Plan says
submitted medical records did not show that a physician is ordering or recommending continuation of
physical therapy. Therefore, the member did not meet Medicare criteria.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

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 additional outpatient PT visits. Our reviewer
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the
enrollee's condition. Our physician reviewer found the requested therapy is not generally accepted as specific
and effective therapy for your condition. You have had prior therapy and the records do not demonstrate that
the unique skills of a professional therapist are required to safely and effectively provide treatment, that the
services can be safely and effectively performed only by a therapist, or by or under the supervision of a
therapist. You and your and caregivers have been instructed on safe transfers. The requested services are not
part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist
required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow
further deterioration.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional outpatient PT visits have not been met. Therefore, we decided that
the Plan does not have to pay for additional PT visits.
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 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 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 medically necessary. Our physician reviewer found the enrollee had a right hip
fracture and surgical repair with minor post-operative complications.
She is currently medically stable with no complex medical, nursing, or rehabilitation needs that require
physical medicine and rehabilitation physician supervision three times per week (at a minimum) for the
ongoing management of any active or acute exacerbations of chronic medical conditions. She does not require
an intensive therapy program 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 pay for surgical services (15860, 49255) provided May 28, 2020.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the documentation does not support the billed services.
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 15860, & 49255 are not supported in the medical record. Specifically, the review
indicates that the enrollee underwent resection of omentum and epiploectomy, however these services were not
substantiated by the clinical documentation. Regarding CPT 15860 there was no documentation of injection of
IV fluorescein to test vascular flow. Based on this information, we decided that Medicare rules for coverage of
the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical
services (15860, 49255) provided May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration 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 medical studies haven't proven that the use of this product during spinal surgery is better
than standard allograft products.
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 there is no specific indication provided to support the request for bone marrow aspirate for the approved
surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone
marrow aspirate for this enrollee's medical condition. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction
with the lumbar surgery performed. Therefore, the request for bone marrow aspiration is not medically
reasonable or necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve bone marrow aspiration for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the left shoulder magnetic resonance imaging (MRI) (73221, 73222, 73223).
You asked the Plan to pre-approve the MRI. You say that the doctor did not want to appeal so you are. The left arm and hand are not working well. The Plan denied your request. The Plan says the enrollee has a pacemaker which is a contraindication for an MRI and is not supported by the documentation submitted by the surgeon.
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records did not show that the enrollee had recently exhausted physical therapy alone prior to considering surgery or imaging. There were no signs or symptoms suggestive of a red flag diagnosis. Therefore, the left shoulder MRI will be considered not medically necessary at this 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the left shoulder magnetic resonance imaging (MRI) (73221, 73222, 73223).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (80307, G0480) rendered by the out-of-network (OON) provider on July 14, 2021.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.

We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the drug testing services (80307, G0480) rendered by the out-of-network (OON) provider on July 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services provided on May 14, 2021, billed with codes 95955 and 95885.

You asked the Plan to pay for the services as billed. You say that the services were billed correctly. The Plan denied your request. The Plan says these codes 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 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).

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 services as billed. Our reviewer says that the billed codes are not supported. Our reviewer found for code 95955, the report indicates that the EEG was symmetric throughout the procedure with no lateralizing events observed. There is a more appropriate code to report for a baseline EEG to report. Any additional EEG monitoring would be included in the primary intraoperative monitoring code. The technical report also does not include documentation of nerve conduction studies which are required to report code 95885. 

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 services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on May 14, 2021, billed with codes 95955 and 95885.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the clinical information provided does not support the medical necessity of care.
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 does not require the intensity of services provided at an inpatient
rehabilitation facility. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative
services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care, such as
skilled nursing facility.
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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve the bedside table.
You asked the Plan to pre-approve the bedside table. You say that the enrollee needs a hospital bed with side rails and the only one that had those was the one with the bed side table. The Plan denied your request. The Plan says a side table is not medically necessary as it does not serve a medical purpose.
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 the bedside table.
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. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and you do not require transfer.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that in this case, you were admitted to the acute care hospital following cardiac arrest while flying. You tested positive for the coronavirus infection despite vaccination. You have had a complicated hospital course. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation
correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815).
You asked the Plan to pre-approve the PETCT. You say that your provider is requesting you to have a PETCT,
of a mass you currently have on your brain. You state that your provider would like the scan to see if the mass
has metastasized. You also state that your provider could not also test the cells of the mass for cancer because it
would be too dangerous to do so due to the area of the brain that the mass is located. The Plan denied your
request. The Plan says there was no documentation submitted with this appeal that established the requested
advance imaging as reasonable and 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 the PETCT. Our physician reviewer
found they did not see evidence of a brain lesion. The notes are from 2020 and not recent. The PETCT is not
recommended for surveillance.
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 PETCT have not been met. Therefore, we decided that the Plan does not
have to pre-approve PET with concurrently acquired CT for attenuation correction and anatomical localization
imaging; skull base to mid-thigh (CPT code 78815).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 

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