Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

 We decided that the Plan has to pay for the 2 units of CPT code 19301. We decided that the Plan does not have to pay for the adjacent tissue transfer (14000).   You asked the Plan to pay for the 2 units of CPT code 19301 and the adjacent tissue transfer (14000). You say that CPT code 19301 was denied for exceeded MUE but 1 is allowed and was not paid. You say that this should be reviewed for medical necessity. The Plan says that CPT code 14000 is considered inclusive to CPT 19301. The Plan also says that CPT code 19301 was not billed per Medicare guidelines.  We decided that the Plan has to pay for 2 units of CPT code 19301.   Our reviewer says that if separate excisions occur on the same breast then modifier 59 would be appropriate with supporting documentation. In this case, the operative report describes 2 lumpectomies in the same breast, with different access to each, and therefore should be paid. Therefore, we decided that the Plan has to pay for the 2 units of CPT code 19301.   We also decided that the Plan does not have to pay for the adjacent tissue transfer (14000).  Our reviewer says that this procedure is inclusive to the partial mastectomy performed, as the incision for the repair is included. This repair performed is not to correct an existing defect, and therefore would not be covered separately. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14000).  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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on August 29, 2021.  You asked the Plan to pay for the ground mileage and non-emergency ambulance transport. You say that these services were medically necessary, and you would like this claim reprocessed for payment. The Plan denied your request. The Plan says the non-emergency ambulance transportation criteria are not met.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 ground mileage and non-emergency ambulance transport. Our reviewer says that the documentation does not support that the ambulance transport on August 29, 2021 was medically reasonable and necessary for the patient. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van) were contraindicated for this patient. Our reviewer also found that the documentation does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on August 29, 2021.   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 ground mileage and non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergency ambulance transport (A0428) provided on August 29, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the drainage of finger abscess (20611), drainage of tendon sheath (26020) and incision and drainage of abscess (10060) provided on March 18, 2021. 
 
You asked the Plan to pay for the drainage of finger abscess (20611), drainage of tendon sheath (26020) and incision and drainage of abscess (10060). You say that this treatment is within the standards of medical practices and immediate payment should be issued. 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 if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the drainage of finger abscess (20611), drainage of tendon sheath (26020) and incision and drainage of abscess (10060). Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found that the member presented with signs and symptoms of infection in the right index finger which was corroborated by imaging. There was gross purulence at the distal extent of the flexor tendon sheath. There were also highly probable areas of at least severe inflammation and plausible/probable infectious areas in the finger pulp, and in and around the index finger tendon sheath. Therefore, the services were 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 the drainage of finger abscess (20611), drainage of tendon sheath (26020) and incision and drainage of abscess (10060) have been met. Therefore, we decided that the Plan has to pay for the drainage of finger abscess (20611), drainage of tendon sheath (26020) and incision and drainage of abscess (10060) provided on March 18, 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: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from July 1, 2021, to July 4, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee was not alert when you tried to obtain their insurance information. You also say that the services should be covered. The Plan denied your request. The Plan says that the medical records did not show that at the time of the inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.  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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee's prolapse was reduced but their sodium was 121. The reviewer found that the documentation indicates that the enrollee had positive occult blood on rectal exam. The reviewer found that the enrollee remained hemodynamically stable and her electrolytes normalized. The reviewer found that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Specifically, the file indicates that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from July 1, 2021, to July 4, 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rotary wing air mileage (A0436) provided on August 4, 2020.    You asked the Plan to pay for the air mileage. You say that this was the closest facility willing to accept the enrollee and capable of treating his malfunctioning internal defibrillator. You also say that you would like this claim to be reprocessed and additional payment made on the 320 miles the enrollee was transported. The Plan denied your request. The Plan says the information provided at the time of the appeal does not support criteria for air ambulance transport for a malfunctioning implantable cardioverter-defibrillator (ICD) defibrillator wire.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 air mileage. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the documentation does support that the patient suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The documentation does not support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. Based on the closer facility being available, the 25-minute transport via ground would have been faster and more appropriate for this patient. Our reviewer found that the documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. Our physician reviewer also found that the destination of this trip was not the nearest appropriate hospital furnished to treat the enrollee. They could have been successfully treated at a closer hospital.  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 air mileage have not been met. Therefore, we decided that the Plan does not have to pay for the rotary wing air mileage (A0436) provided on August 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Vitamin D hydroxy provided on June 29, 2021 to June 30, 2021.  

You asked the Plan to pay for the Vitamin D hydroxy. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.  

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  

The Vitamin D hydroxy test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the Vitamin D hydroxy provided on June 29, 2021 to June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 provided on May 11, 2020.  You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in a Nursing Facility, place of service 32. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 87496, 87498, 87631, 87798, 87486, 87541, 87581, and 87640 provided on May 11, 2020.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve use of Euflexxa.  You asked the Plan to pre-approve Euflexxa. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because repeat Euflexxa injection is considered medically necessary if at least 6 months have elapsed since the last injection in the series.  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 Euflexxa. Our reviewer says that the enrollee meets the Medicare criteria for the requested use of Euflexxa. Our physician reviewer found the enrollee has osteoarthritis of the knees and received Euflexxa in September 2021. The Food & Drug Administration (FDA) has stated that the requested drug is indicated for the enrollee's condition. Medicare drug compendia do not restrict the timing of repeat administration. Therefore, the requested service is recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have been met. Therefore, we decided that the Plan has to pre-approve use of Euflexxa.   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 radiofrequency ablation at the sacroiliac joint for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that radiofrequency ablation of the nerves innervating the sacroiliac joint has not been proven as effective as standard treatment of sacroiliac joint pain.  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 requested services are not considered medically reasonable and necessary in this case. According to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of sacroiliac joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation at the sacroiliac joint for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on January 4, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had a listed diagnosis of depressive type schizoaffective disorder. The case file contains a GeneSight Order Medical Necessity Documentation form, and the results of the GeneSight testing. The case file does not contain additional clinical information. The documentation is insufficient to support that the GeneSight genetic testing was medically reasonable and necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on January 4, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for a targeted genomic sequence analysis panel received on June 20, 2021.  You asked the Plan to pay for the services. You say that this is medically necessary for a patient with cancer. The Plan denied your request. The Plan says that this test is unlikely to impact therapeutic decision-making in the clinical management of the patient.  The Plan must follow Medicare rules. Medicare rules say that genetic testing is covered when the test is accepted by the medical community, and the testing will affect the medical management of the patient.  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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found hemangiopericytomas are rare, dural-based tumors accounting for less than 1 percent of all primary central nervous system (CNS) tumors. They are biologically aggressive tumors for which no standard treatments exist in the recurrent setting. The development of sophisticated genetic and molecular characterization of CNS neoplasms has shown that histologically similar neoplasms can be characterized more accurately for prognosis and in some instances for response to different therapies. Molecular characterization of primary brain tumors/gliomas has had a substantial impact on stratification and eligibility in clinical trials for CNS neoplasms over the last 10 years, and is increasingly becoming a common part of standard neuro-oncology management. The National Comprehensive Cancer Network guidelines recommend molecular profiling to identify clinically relevant subtypes to encourage opportunities for clinical trial involvement. FoundationOne testing of this enrollee's treatment has the potential to guide therapeutic decision making in terms of clinical trials, appealing for compassionate drug use, or identifying markers for which existing therapies may exist. It is considered a standard of care. The service is reasonable and 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 services have been met. Therefore, we decided that the Plan has to pay for a targeted genomic sequence analysis panel received on June 20, 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 pay for the acute inpatient hospital care provided from 3:45 pm on March 9, 2020, to 11:23 pm on March 10, 2020.  You asked the Plan to pay for the inpatient care provided from 3:45pm on March 9, 2020, to 11:23 pm on March 10, 2020. You say that the services provided were appropriate, medically reasonable, and necessary. The Plan denied your request. The Plan says the enrollee was stable for transport to a Plan facility as of 3:45 pm on March 9, 2020.  The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.   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 care provided from 3:45pm on March 9, 2020, to 11:23 pm on March 10, 2020. Our reviewer says that the inpatient care was not medically necessary. Our physician reviewer found that the provided documentation indicates that all subsequent inpatient care provided after 3:44 pm on March 9, 2020 through 11:23 pm on March 10, 2020, was not needed on an emergent basis at the non-Plan facility. The reviewer found that the enrollee, after 3:44 pm on March 9, 2020, was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility. Therefore, the reviewer found that post stabilization care services at the non-Plan facility were not medically necessary or reasonable.  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 inpatient care provided from 3:45pm on March 9, 2020, to 11:23 pm on March 10, 2020 have not been met. Specifically, the file indicates that the enrollee was stable for transport to an inpatient facility as of 3:45 pm on March 9, 2020. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from 3:45 pm on March 9, 2020, to 11:23 pm on March 10, 2020.