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

We decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis (74177).
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis (74177). You say that the requested CT scan of the abdomen and pelvis (74177) is medically necessary. The Plan denied your request. The Plan says the requested CT scan of the abdomen and pelvis (74177) is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 a CT scan of the abdomen and pelvis (74177). Our reviewer says that the requested CT scan of the abdomen and pelvis (74177) is not medically necessary. Our physician reviewer found the reviewed documentation indicates that the enrollee was seen on February 1, 2022. It was noted that he has been having abdominal pain for 2 weeks. He previously had a CT scan of the abdomen and pelvis which demonstrated abnormal gastric wall thickening and irregularity. Objectively, the enrollee was found to have left lower quadrant tenderness and mild to moderate right lower quadrant tenderness. In this case, the criteria for the abdomen and pelvis requires that a urinalysis be performed, and it be negative for there is a negative fecal occult blood test (FOBT). In this instance, this was not clearly noted in the documentation. It was also noted that this enrollee had similar issues before where CT scan did demonstrate an irregularity which was not clearly expanded upon. The review has determined that the requested CT scan 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 a CT scan of the abdomen and pelvis (74177) have not been met. Therefore, we decided that the Plan does not have to pre-approve a CT scan of the abdomen and pelvis (74177).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray provided on July 2, 2021.
You asked the Plan to waive the copayment for an x-ray. You say that this service should be covered since it
was over four years ago you had it done. The Plan denied your request. The Plan says the proper copayment
was applied,
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $45
copayment for each Medicare-covered x-ray. The total amount allowed was $42.48 which is lower than the
copayment amount of $45. Therefore, the copayment charged was only $42.48.
You have been asked to pay a $42.48 copayment for an x-ray. An x-ray falls within Outpatient diagnostic tests
and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
an x-ray provided on July 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted femur or knee procedure (27599) provided on
June 23, 2021.
You asked the Plan to pay for the unlisted femur or knee procedure (27599). You say that the documentation is
attached, and the claim should be processed for payment. The Plan denied your request. The Plan says the
billed procedure code 27599 does not appear on the list of covered surgical procedures in an ambulatory
surgical center.
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 27599 is unlisted procedure, femur or knee.
We find that CPT code 27599 is not supported in the medical record. Specifically, the unlisted femur or knee
procedure (27599) is not on the list of covered procedure codes which may be performed in an ambulatory
surgical center. Based on this information, we decided that Medicare rules for coverage of the unlisted femur or
knee procedure (27599) have not been met. Therefore, we decided that the Plan does not have to pay for the
unlisted femur or knee procedure (27599) provided on June 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings with a zipper.

You asked the Plan to pre-approve the compression stockings. You say that you would like reconsideration because you require the zipper due to your condition. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the compression stockings are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings with a zipper.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says continued admission in a skilled nursing facility does not meet the requirements for
approval.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you do not have any documented skilled
nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance
program or to prevent deterioration of your condition. You no longer qualify for SNF coverage.
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 continued admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from August 11, 2020,
through August 13, 2020, and billed with the secondary diagnosis code I69.351.
You asked the Plan to pay for the inpatient hospital care as billed. You say that the inpatient hospital care was
billed correctly as submitted. The Plan denied your request. The Plan says the documentation does not support
the inpatient hospital care as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with secondary diagnosis code, I69.351, defined as
hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. We asked our
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for the inpatient hospital care as billed. Our reviewer says that
the documentation does not support the billed secondary diagnosis code. Our physician reviewer found the
patient is an 82-year-old female with ovarian cancer who was admitted to the hospital. She had a scheduled
surgery for resection of the pelvic mass which was tolerated and without complication. Hemiplegia and
hemiparesis following cerebral infarction affecting right dominant side was listed as a secondary diagnosis for
this admission. However, there was insufficient evidence found in the notes such as symptoms or imaging
results to confirm this diagnosis as directly related to this admission. The provided documentation does not
support the diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant
side.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital care provided from August 11, 2020, through August 13, 2020, and billed with the
secondary diagnosis code I69.351.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient psychiatric services provided from April 18, 2021, to June
7, 2021.
You asked the Plan to pay for the inpatient psychiatric services. You say that the services were medically
necessary. The Plan denied your request. The Plan says that the services you received were not medically
necessary.
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. Specifically, the case file indicates that the Plan had the appropriate clinical
documentation for the requested dates of service. The record also shows that the Plan used this clinical
documentation to support their denial. Relevant clinical information for the billed dates of service has not been
forwarded. Of note, we specifically requested these medical records, and they were not sent. It is the burden of
the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been
substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the inpatient
psychiatric services provided from April 18, 2021, to June 7, 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria is not met.
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 currently undergoing treatment at an acute care hospital (ACH) for chronic wounds, a leaking ostomy and infectious diarrhea. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) admission.
You asked the Plan to pre-approve the LTACH admission. You say that the LTACH admission is medically
necessary. The Plan denied your request. The Plan says you are receiving appropriate care in the hospital and
there is no advantage in transferring to the LTACH at this time.
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 admission. Our reviewer
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the provided documentation indicates that the enrollee is gradually improving after a
prolonged hospital stay but still requires acute care services. The reviewer found that the enrollee continues to
receive acute care services, and these have not been denied.
The provided documentation does not indicate that the enrollee requires services that she is 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 admission have not been met. Specifically, the file does not show
that the enrollee requires services that she is not currently receiving but that would be available at the LTACH
facility. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital
(LTACH) admission.
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 services are medically necessary. The
Plan denied your request. The Plan says coverage criteria has not been met.
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 record indicates that the enrollee is not able to be weaned from mechanical
ventilation due to agitation when not sedated. The enrollee continues to receive acute care services and these
have not been denied. The medical record does not indicate that the enrollee requires services that she is 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0553, K0554).
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose
monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been
met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations,
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment
plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of
the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0553, K0554).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee was admitted with altered mental status due to sepsis from pneumonia. The record indicates that the enrollee is improving and is being weaned from ventilatory support. The record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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 for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you are ready to move to a rehab setting. The
Plan denied your request. The Plan says that your records do not show that you require daily skilled services
that can only be provided on an inpatient basis.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) additional home physical therapy (PT) visits
(G0151).
You asked the Plan to pre-approve additional home PT visits. You say that the requested additional home PT
visits are medically necessary. The Plan denied your request. The Plan says the requested additional home PT
visits do not meet 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 pre-approve additional home 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 enrollee with debility from acute illness is medically
stable with good functional mobility, does not meet criteria for the requested additional therapy visits beyond
the date January 13, 2022. 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 the patient's 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 home PT visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve eight (8) additional home physical therapy (PT) visits (G0151).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.
You asked the Plan to pre-approve Genvisc. The Plan denied your request. The Plan says the enrollee has not
tried and failed Orthovisc and Synvisc or Synvisc One.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 Genvisc. Our physician reviewer found
that the enrollee has a diagnosis of bilateral osteoarthritis of the knees. The Plan requires a trial of Orthovisc
and Synvisc or Synvisc One before they will approve the requested drug. The case file does not contain
documentation of trial and failure of the required drugs. The documentation does not support that the required
drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have
to pre-approve Genvisc.