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

We decided that the Plan does not have to pre-approve facet joint injections-lumbar spine (CPT code(s) 64493
and 64494), for the enrollee.
You asked the Plan to pre-approve the injections. You say that it is medically necessary based on spondylosis
without myelopathy or radiculopathy, lumbar region. The Plan denied your request.
The Plan says as the basic criteria has not been met and the requested clinical information (results of current
radiographic studies) not provided the request cannot be approved and is not considered reasonable and
necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the injections. Our physician reviewer
found criteria for facet injections not met. The last documented x-ray is from 2014. More resent imaging is
needed.
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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve facet joint injections-lumbar spine (CPT code(s) 64493 and 64494), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PET with concurrently acquired CT for attenuation
correction and anatomical localization imaging; skull base to mid-thigh (CPT code 78815) to be provided by an
out-of-network provider.
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your
request. The Plan says there are available diagnostic imaging providers in the enrollee's network.
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 PET with concurrently acquired CT for attenuation correction and
anatomical localization imaging; skull base to mid-thigh (CPT code 78815) to be provided by an out-ofnetwork
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the required services exceed the clinical
capabilities of lower levels of care. The Plan denied your request. The Plan says the enrollee has not required a
prolonged acute inpatient admission.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician
reviewer found that the enrollee was admitted to the acute hospital with abdomen pain and constipation. She
was found to have colon cancer. The enrollee is receiving appropriate care at the present acute care hospital.
There are no services available at the LTACH that the enrollee requires that are not available at the health care
setting being offered by the health plan. Therefore, the requested LTACH services are 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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH 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 IRF care is medically necessary for this enrollee. The
Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services
can be provided in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's 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 this enrollee
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 neuromuscular services represented by codes 95955 and 95937 provided on January 12, 2021.
You asked the Plan to pay for codes 95955 and 95937. You say that the medical records support the billing of codes 95955 and 95937. The Plan denied your request. The Plan says the medical records do not support the billing of codes 95955 and 95937.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.
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 95955 and 95937. Our reviewer says that the medical records do not support the billing of codes 95955 and 95937. Our reviewer found the technical report documents "real time EEG monitoring" was performed. CPT 95955 is an inappropriate code to report for this service. Any addition EEG monitoring during procedure would be inclusive to the primary code (when reported correctly) for EEG during nonintracranial surgery. For CPT 95937, technical report does not document this procedure. If provider is reporting a train of four for this code, this is an incorrect code to report for this service. Train of four is inclusive to the primary service and would not be reported separately. 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 95955 and 95937 have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular services represented by codes 95955 and 95937 provided on January 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the long term acute care hospital (LTACH) services provided from April 26, 2021, to May 14, 2021.
You asked the Plan to pay for the LTACH services. You say that this enrollee did meet LTACH admission and continued stay criteria for the duration of his hospitalization until a safe discharge plan was established. The Plan denied your request. The Plan says the enrollee was stable for transfer to a Skilled Nursing Facility on May 12, 2021 and did not meet continued stay criteria for a LTACH. The Plan also says that since the entire inpatient stay was billed on together on one claim, the denial is correct as authorization has been exceeded.
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 pay for the LTACH services.
Our reviewer says that the requested LTACH care provided on May 13, 2021, and May 14, 2021 was not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating continued services at the LTACH. The enrollee did not require services at the LTACH that were not available at a skilled nursing facility. Our reviewer found that there were no services available at the LTACH that the enrollee required that were not available at the health care setting being offered by the health plan. Our physician reviewer also found that the requested LTACH services were not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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. The Plan approved dates from April 26, 2021, to May 12, 2021 are also being upheld as the claim was billed with dates that were not medically necessary and unauthorized. Therefore, we decided that the Plan does not have to pay for the long term acute care hospital (LTACH) services provided from April 26, 2021, to May 14, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the pain is not predominantly axial, and there is evidence of persistent radiculopathy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found that in this case, the enrollee has radiculopathy. The facet joint is not the main source of pain. The review has determined that the enrollee does not meet the coverage criteria detailed in the LCD. 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 facet joint injections for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Coflex device (22867).
You asked the Plan to pre-approve the insertion of a Coflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is only covered under clinical trials.
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 insertion of a Coflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show it is safe and effective. 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 insertion of a Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Coflex device (22867).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction (92015) provided on June 9, 2021.
You asked the Plan to pay for the eye refraction. You say that this service should be covered because it is necessary, and you were directed to fill out a claim reimbursement form by the Plan. The Plan denied your request. The Plan says eye refractions are not covered by Medicare. The documentation indicates that this eye refraction was routine, which is covered by an outside carrier.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. In order to receive reimbursement for out-of-network services, you are responsible for submitting the out-of-network claim form with itemized receipt directly to the routine vision carrier as specified in the Plan's contract. We looked at the file and the Plan's rules. The refraction may be covered by the Plan's supplemental vision benefit, but this service is provided by another carrier. You must submit the reimbursement form and itemized receipt to the correct entity to receive reimbursement for out-of-network routine vision care. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction (92015) provided on June 9, 2021.
Your complaint about a potential miscommunication from the Plan regarding processing your reimbursement information is not a valid appeal for medical coverage. Based on the information sent with your appeal, it appears that this information was mistakenly sent to the Medicare Advantage Plan in a pre-addressed envelope you received. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing
needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required
to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial
and, as a practical matter, can be provided at a lower level of care.
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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
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 enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
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 there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Favorable

We decided that the Plan has to pay for intubation, endotracheal, emergency procedure (CPT code 31500) and 
critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes 
(CPT code 99291-25) provided to the enrollee on November 15, 2020. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the services are not supported by the records. 
 
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer found the documentation does 
support the code 31500 and 99291-25 were performed on November 15, 2020, were performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
intubation, endotracheal, emergency procedure (CPT code 31500) and critical care, evaluation and 
management of the critically ill or critically injured patient; first 30-74 minutes (CPT code 99291-25) provided 
to the enrollee on November 15, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-elastic gradient compression wrap (A6545).
You asked the Plan to pre-approve compression wrap. You say that you are appealing with supporting records.
The Plan denied your request. The Plan says the denial of authorization for this item is correct, because the
enrollee has not had a debridement of their wounds.
The Plan follows Medicare rules. Medicare rules state that a compression wrap A6545 is only covered for
enrollees who have a qualifying wound.
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 compression wrap. Our reviewer says
that the enrollee does not meet the Medicare criteria for the requested dressing. Our physician reviewer found
the record indicates that the enrollee has chronic venous insufficiency ulcers but does not indicate that any type
of debridement has been performed. Therefore, the elements of the coverage criteria have not been satisfied.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of compression wrap have not been met. Therefore, we decided that the Plan does
not have to pre-approve a non-elastic gradient compression wrap (A6545).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat facet joint injections (medial branch radiofrequency ablations (RFAs)).
You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the previous injections only helped for 7 days with about 40-60% pain relief.
The Plan follows Medicare rules. Medicare rules state that therapeutic facet joint interventions may be covered under certain clinical conditions. 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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint interventions. Our physician reviewer found the enrollee has had multiple facet joint injections with either no relief, minimal relief, or short-lived relief. The longest period of time reported is approximately 2 weeks. According to the coverage criteria, at least 80% improvement for 3 months is required. The enrollee does not meet this requirement. In addition, a series of two medial branch blocks (MBBs) to diagnose facet pain is required due to the unacceptably high false positive rate of single medial branch blocks. Dual MBBs must result in 80% relief that is documented. The enrollee has only had one MBB with 40-60% pain relief. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat facet joint injections (medial branch radiofrequency ablations (RFAs)).