Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility or home with home health and home physical therapy.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis after recent repair of an open ankle fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy, and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT code 36248), vascular embolization or occlusion (CPT code 37242), ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (CPT code 76937), selective catheter placement (CPT code 36247), and vascular embolization or occlusion (CPT code 37243), to be provided by an out-of-network provider.  You asked the Plan to pre-approve the out-of-network services. You say that the enrollee was referred by their primary care provider. You state that you have both a referral and authorization from this health plan on file to treat this enrollee as an out-of-network provider. The Plan denied your request. The Plan says the medical record received did not show that the enrollee has an emergent or urgent medical condition or are in need of specialized service. The Plan states there are in-network provider(s) within a reasonable distance from the enrollee's location that can provide this service/item.  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 selective catheter placement, arterial system; additional second order, third order, and beyond, abdominal, pelvic, or lower extremity artery branch, within a vascular family (CPT code 36248), vascular embolization or occlusion (CPT code 37242), ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites (CPT code 76937), selective catheter placement (CPT code 36247), and vascular embolization or occlusion (CPT code 37243), to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tier exception for Yupelri.  You asked the Plan to pre-approve a tier exception. You say that the cost of this drug is very high. The Plan denied your request. The Plan says that tier exceptions are only available for Part D drugs.  The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs.   The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Yupelri.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Osteogenesis stimulator (E0747).  You asked the Plan to pre-approve an Osteogenesis stimulator. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written interpretation by a treating practitioner stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Osteogenesis stimulator have not been met. Specifically, there is not a minimum of two sets of radiographs separated by a minimum of 90 says. Therefore, we decided that the Plan does not have to pre-approve an Osteogenesis stimulator (E0747).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from March 15, 2021 to March 19, 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 submitted records do not support the billing of primary diagnosis A41.9 and secondary diagnosis R65.20.  

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 principal diagnosis A41.9 (sepsis, unspecified organism) and secondary diagnosis R65.20 (severe sepsis without septic shock). 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 submitted records do not support the billing of primary diagnosis A41.9 and secondary diagnosis R65.20. Our physician reviewer found the records support an admission for further evaluation and treatment of acute cystitis. While severe sepsis was documented on admission in the emergency department, other medical documentation is incomplete regarding this condition. The discharge summary documentation included, admitted for syncope and hypernatremia due to dehydration as well as severe sepsis due to urinary tract infection. There was no documentation of sepsis. The primary and secondary diagnoses are therefore not supported.   

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 services rendered from March 15, 2021 to March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the intracept procedure (CPT code(s): 64628 and 64629), for the enrollee.  You asked the Plan to pre-approve the services. You say that the intracept procedure is designed to address chronic low back pain that is identified by modic changes. The Plan denied your request. The Plan says the intracept procedure is considered unproven as its clinical value and effectiveness have not been demonstrated in the peer-reviewed literature. The Plan states more research is needed to show safety and efficacy of the procedure.  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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show safety and efficacy.  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 the intracept procedure (CPT code(s): 64628 and 64629), for the enrollee.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the services (88377) provided on June 9, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billing of code 88733 with modifier -91 is not supported.  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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a gastric carcinoma. The provider stated they performed an additional test with different results. The provider also stated that the ordering physician determined the specialized testing was medically necessary for the diagnosis, monitoring and/or appropriate medical management of the enrollee.  We looked at this physician's review, the file, and Medicare rules. The documentation supports the billing of code 88733 with modifier -91 as medically reasonable and necessary. 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 the services (88377) provided on June 9, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (71045) provided on September 24, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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, we have confirmed that code 71045 is a column II code to column I code 71046. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (71045) provided on September 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554) and supplies (K0553).  You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says you are not insulin treated.  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 a Freestyle Libre continuous glucose monitor, and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554) and supplies (K0553).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Esomeprazole Magnesium for the enrollee.  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 Esomeprazole Magnesium for the enrollee.   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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Pembrolizumab (J9271).  

You asked the Plan to pre-approve Pembrolizumab. The Plan denied your request. The Plan says there was no evidence presented that indicates Pembrolizumab will work once the disease has grown after previously receiving Nivolumab.  

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Pembrolizumab. Our reviewer says that Pembrolizumab (J9271) is not medically reasonable and necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of metastatic renal cell carcinoma that has progressed on therapy. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's specific clinical condition. Our reviewer found that the Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's specific clinical situation. No literature from Medicare approved cancer journals were submitted for review. Our physician reviewer also found that the elements of the coverage criteria are not satisfied, and the requested service cannot be 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 Pembrolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Pembrolizumab (J9271).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an inpatient hospital admission for a total knee arthroplasty.  You asked the Plan to pre-approve inpatient services. You say that the enrollee is significantly limited in daily activities. The Plan denied your request. The Plan says the procedure can be done in an outpatient setting.  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.   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 requested services. Our physician reviewer found that the enrollee is being treated for chronic severe arthritis and degenerative joint disease of the right knee. He is significantly limited in daily life and reports he cannot walk further than a block before he has to sit down and rest due to pain in the knee. He struggles with daily activities due to pain in the knee. The right total knee arthroplasty was approved. However, detailed documentation is not evident regarding a significant past and/or current medical history that would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for an inpatient stay for the approved right total knee arthroplasty 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission for a total knee arthroplasty.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).  You asked the Plan to pre-approve endosteal implants. You say that you cannot take the dentures you were given, and your dentist is recommending implants. You also say that you need the implants because you are having trouble eating. The Plan denied your request. The Plan says this service is not covered under your benefit plan.           Therefore, we decided that the Plan does not have to pre-approve surgical placements of implant bodies: endosteal implants (D6010).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Suture of quadriceps or hamstring muscle rupture (27385-LT and 27385-59-LT) provided on May 2, 2021.  You asked the Plan to pay for codes 27385-LT and 27385-59-LT. You say that the medical records support the billing of codes 27385-LT and 27385-59-LT provided on May 2, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 27385-LT and 27385-59-LT provided on May 2, 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. The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  In this case, the CPT Code Manual definition of code 27385-LT is Suture of quadriceps or hamstring muscle rupture; primary.  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 codes 27385-LT and 27385-59-LT. Our reviewer says that the medical records do not support the billing of codes 27385-LT and 27385-59-LT provided on May 2, 2021. Our reviewer found the medical records provided indicate that CPT 27524 - open treatment of patellar fracture with internal fixation and/or partial or complete patellectomy and soft tissue repair.  CPT 27385 LT and 27385 59 LT have a bundled relationship with 27524, however the use of an appropriate modifier is allowed to unbundle these services providing the medical records support the use of the modifier.  In this case, the medical records provided do not include sufficient documentation to validate that 27385 LT and 27385 59 LT were performed as distinct, separate procedures, therefore, it is inappropriate to use a modifier to unbundle these services from 27524 and no additional reimbursement is allowed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 27385-LT and 27385-59-LT have not been met. Therefore, we decided that the Plan does not have to pay for the Suture of quadriceps or hamstring muscle rupture (27385-LT and 27385-59-LT) provided on May 2, 2021.