Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantable loop recorder (33286, 33285).
You asked the Plan to pre-approve implantable loop recorder. You say that the etiology of the enrollee's palpitations with associated dizziness remains unclear and is concerning, and recommendation is for loop
recorder replacement for continued long term rhythm management. The Plan denied your request. The Plan says the records do not meet medical necessity criteria.
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 implantable loop recorder. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has had an implantable loop recorder in place for over 3 years with no recent actionable findings. The enrollee's evaluation has been negative for ischemia, and the criteria for arrhythmic right ventricular cardiomyopathy have not been met. The documentation does not support that continuation of the implantable loop recorder is 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 implantable loop recorder have not been met. Therefore, we decided that the Plan does not have to pre-approve implantable loop recorder (33286, 33285).
Sincerely,
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rhopressa solution.

You asked the Plan to pre-approve Rhopressa solution. You say that the enrollee has failed other medications.
The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's
prescription drug plan.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Rhopressa solution.

Benefits for Rhopressa solution 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81249, 81256, 81283, 81291, 81328, 81335, 81350, 81400, 81401, 81406, 81408, 0031U, 0032U, 0033U) provided on March 12, 2021.

You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with the correct place of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81225, 81226, 81227, 81230, 81231, 81232, 81240, 81241, 81249, 81256, 81283, 81291, 81328, 81335, 81350, 81400, 81401, 81406, 81408, 0031U, 0032U, 0033U) provided on March 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement CPAP device (E0601).

You asked the Plan to pre-approve a CPAP device. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for replacement equipment have not been met.

The Plan must follow Medicare rules. Medicare rules say that, in the absence of program instructions, the reasonable useful lifetime of equipment in no case can be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the enrollee, not the age of the equipment. 

We looked at the file and Medicare rules. In this case, you are requesting a replacement for a CPAP. The case record indicates that the requested replacement is for an item that has not outlasted its reasonable useful lifetime. Based on this information, we decided that Medicare rules for coverage of a replacement CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement CPAP device (E0601).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA genetic testing for the enrollee.

You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no personal history of breast, ovarian, pancreatic or prostate cancer.

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 test at issue in this appeal, the testing, is being 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 pre-approve BRCA genetic testing for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomepra magnesium caplet 40mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the plan does not cover outpatient prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Esomepra magnesium
caplet 40mg for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion interspinous spacer 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 this service is considered experimental and investigational.
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. The superion spacer is experimental. More research is needed to show safety and efficacy. 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 the Superion interspinous spacer for the enrollee.
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 to be discharged to an IRF so you can recover fully before returning home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in another setting.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray provided on June 2, 2021.
You asked the Plan to pay for the x-ray. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of code 71045 is radiologic examination, chest; single view. We find that CPT code 71045 was billed with code 71046. CPT code 71045 may be eligible for payment when billed with this code pair. However, the claim does not show that a modifier suitable for payment was billed. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray provided on June 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested drug is intended for patient self-administration.
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 Horizant for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospice services (99222), provided on November 3, 2020.

You asked the Plan to pay for the hospice services. You say that the services were medically necessary. The Plan denied your request. The Plan says the member was enrolled in hospice.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the hospice services (99222), provided on November 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network occupational therapist for
the enrollee.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says there is no network gap as there are in-network providers.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
a referral to an out-of-network occupational therapist for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) for the enrollee.

You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says the height adjustment feature is a convenience feature.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care with an out-of-network podiatrist.

You asked the Plan to pre-approve continued care with an out-of-network podiatrist. You say that the requested
continued care with the out-of-network podiatrist is medically necessary. The Plan denied your request. The
Plan says the requested continued care with the out-of-network podiatrist is not medically necessary.

Medicare rules generally allow plans to restrict enrollees to using plan providers if there are plan providers
available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use
contract providers for care.

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 continued care with an out-of-network
podiatrist. Our reviewer says that the requested continued care with the out-of-network podiatrist is not
medically necessary. Our physician reviewer found after careful review of the enclosed information and the
pertinent guidelines for this case, this enrollee's medical management and/or follow-up care can be safely
transitioned to an in-network podiatrist. It is well documented that this enrollee saw her out-of-network
podiatrist on April 8, 2021, for treatment of metatarsalgia, hammertoes, onychomycosis, ingrown toenails, and
foot pain bilaterally. The enrollee was treated by her current out-of-network podiatrist. After review of the
medical information, there does not appear to be anything unique about this enrollee's conditions that would
make it medically necessary for her to continue care with the out-of-network podiatrist. The current
assessments for this enrollee are standard foot ailments and within the treatment abilities of most if not all
podiatrists. The medical documentation does advise that this enrollee is receiving active treatment from her
out-of-network podiatrist, however the enrollee's conditions are such that it would not be inappropriate or
contraindicated to transition her to an in-network podiatrist 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 continued care with an out-of-network podiatrist have not been met. Therefore,
we decided that the Plan does not have to pre-approve continued care with an out-of-network podiatrist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crowns (D2740 x 2), core build up (D2950 x 2), adjunctive pre-diagnostic test (D0431), a root canal for an anterior tooth (D3310), and a root canal for a molar (D3330).
You asked the Plan to pre-approve the dental services. You say that you are on constant pain when you move your jaw. You say that you previously received a partial overturn for the services that you requested. You say that you did not get the services as you were confused. You also say that you are still in great need of oral care. The Plan denied your request. The Plan says crowns, core build up, adjunctive pre-diagnostic testing, and root canals are not listed as covered dental services.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested crowns, core build up, adjunctive pre-diagnostic testing, and root canals are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve crowns (D2740 x 2), core build up (D2950 x 2), adjunctive pre-diagnostic test (D0431), a root canal for an anterior tooth (D3310), and a root canal for a molar (D3330).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mastectomy represented by code 19307 provided on
April 6, 2021.

You asked the Plan to pay for code 19307. You say that the medical records support the billing of code 19307
provided on April 6, 2021. The Plan denied your request. The Plan says the medical records do not support the
billing of code 19307 provided on April 6, 2021.

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 19307 is Mastectomy, modified radical, including
axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle.

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 code 19307. Our reviewer says that the medical records do
not support the billing of code 19307 provided on April 6, 2021. Our reviewer found the record indicates that
the enrollee underwent a procedure. The operative note indicates that a skin sparing total mastectomy was
performed. The operative note describes the performance of a skin sparing mastectomy with periareolar
incision. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 19307 have not been met. Therefore, we decided that the Plan does not
have to pay for the Mastectomy represented by code 19307 provided on April 6, 2021.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting; the LTACH would add no additional services.

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 that the enrollee appears to be gradually stabilizing with current treatment but requires additional acute care services that can safely be administered at the current facility until appropriate for discharge to a lower level of care. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary at this time as there is no clinical advantage to transfer at this time. Transfer may be considered when more stable and when treatment has completed.

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 pay for the electrocardiogram, routine ECG with at least 12-leads,
interpretation and report only (93010) provided January 12, 2021.

You asked the Plan to pay for the ECG services. You say that two EKGs were performed on January 12, 2021.
You had a 76 modifier to indicate this. The reports are attached to support your charges and for
reconsideration. The Plan denied your request. The Plan says this is an exact duplicate claim/service.

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 93010 is electrocardiogram, routine ECG with at least
12-leads; interpretation and report only.

We find that CPT code 93010 is not supported in the medical record. Specifically, another claim was billed
with the same exact code, by the same provider, for the same date of service which was processed and paid on
February 23, 2021. Based on this information, we decided that Medicare rules for coverage of the ECG
services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram,
routine ECG with at least 12-leads, interpretation and report only (93010) provided January 12, 2021.