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

We decided that the Plan does not have to pay for an additional x-ray provided on April 21, 2021.
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says only one unit it
supported.
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 71045 is "Radiologic examination, chest; single view."
We find that an additional unit of CPT code 71045 is not supported in the medical record. Specifically, the
records show that one x-ray was provided on April 21, 2021, which was previously paid by the Plan. 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 an additional x-ray provided on April 21, 2021
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 the best option. The Plan denied your
request. The Plan says an intensive rehabilitation program is not medically necessary.
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. Medical problems are
stable. There are no complex nursing or rehabilitation needs. 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95927, and 95908 provided on December 22, 2020.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical records provided. The Plan denied your request. The Plan says the documentation does not support the codes as billed.
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 codes 95955, 95885, 95927, and 95908 are as follows: 95955 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)
95885 - Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure) 95927 - Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 95908 - Nerve conduction studies; 3-4 studies 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 medical services. Our reviewer says that the medical documentation does not support the codes in question. Our reviewer found that regarding CPT code 95955, the documentation supports real time imaging was performed. This is the incorrect code to report for this service. Any addition electroencephalogram performed during procedure would be included in the appropriate primary code. Regarding CPT 95885, the documentation does not support nerve conduction testing which is performed when reporting this code. Therefore, this procedure would not be covered. Next, CPT 95927 indicates that this procedure is not documented as performed in the technical report, and therefore cannot be confirmed as performed. For CPT 95908, the documentation supports Pedicle screw stimulations, this is not considered nerve conduction studies which include amplitude, latency/velocity. Therefore, this service would not be covered. 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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95927, and 95908 provided on December 22, 2020.
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), for the enrollee.
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 the request cannot be approved because the enrollee's records show that they have had a detailed picture study to look at the enrollee's organ and tissue function (PET) to help plan the enrollee's treatment. The Plan states repeat PET scans are not supported for treatment planning.
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 PET scan. Our physician reviewer found pulmonary nodule is FDG avid, biopsy is now indicated. Repeat PET CT will not change clinical course and is unnecessary. 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 PET scan have not been met. 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), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy services (CPT code(s): 97014,
97035, 97110, and 97010) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the physical therapy services. You say that the enrollee would like to see an
out-of-network therapy provider that is close to their home. The Plan denied your request. The Plan says there
are in-network providers that can provide the physical therapy services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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
the physical therapy services (CPT code(s): 97014, 97035, 97110, and 97010) to be provided by an out-ofnetwork
provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from June 6, 2021, 
through July 5, 2021. 

You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says 
continuation of SNF services is not medically necessary. 
 
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 pay for continuation of SNF services. Our reviewer 
says that daily skilled services are not medically necessary. Our physician reviewer found that based on the 
documentation provided, the enrollee no longer qualified for SNF coverage. The enrollee did not have 
documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled 
services were not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollee's condition. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the 
Plan does not have to pay for continuation of SNF services provided from June 6, 2021, through July 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need a lot of help and it would be unsafe 
discharge. The Plan denied your request. The Plan says the stay is not medically necessary. 
 
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 there are no identifiable skilled nursing 
service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or 
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an 
inpatient basis in a SNF setting. 
 
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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 home health aide visits and 2 additional skilled 
nursing visits. 
 
You asked the Plan to pre-approve 15 home health aide visits and 2 additional skilled nursing visits. You say 
that the home health visits are to help the enrollee shower. You also say that the enrollee needs to use a Hoyer 
lift to shower. The Plan denied your request. The Plan says the requested visits are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 15 home health aide visits and 2 
additional skilled nursing visits. Our reviewer says that 15 home health aide visits and 2 additional skilled 
nursing visits are not medically necessary. Our physician reviewer found the enrollee does not have 
documented skilled nursing needs. Therefore, the reviewer found that the requested home health skilled nursing 
services, and associated home health aide services, are not shown to be 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 15 home health aide visits and 2 additional skilled nursing visits have not been 
met. Specifically, the file does not indicate that the enrollee has any skilled nursing needs. Therefore, we 
decided that the Plan does not have to pre-approve 15 home health aide visits and 2 additional skilled nursing 
visits.
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 enrollee has multiple ongoing medical problems that will require daily physician involvement and assessments which will require treatment. The Plan denied your request. The Plan says the stay is not medically necessary.
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 necessitating 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 they are 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 LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
You asked the Plan to pre-approve periodontal scaling and root planing. You say that this service is necessary because you are having a hard time putting your dentures in. The Plan denied your request. The Plan says this service is not covered under your benefits.
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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth per quadrant (D4341).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702) for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature shows that this device does not have proven benefit, and 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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.
The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PUREWICK  external female urine collection
device, for the enrollee.
You asked the Plan to pre-approve the device. You say that the enrollee has a prolapsed bladder, so they often
leak into a diaper as they are walking to get to the bathroom. The Plan denied your request. The Plan says the
device does not meet the Plan's 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 the device. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the PUREWICK device does not meet the Plan's coverage criteria. Specifically, the enrollee is
not bed confined/ immobile and requiring full assist from bed to chair, has not been deemed at risk for
indwelling catheterization by a specialist, does not have a history of current or previous decubitus ulcers/skin
breakdown/injury in the sacral or gluteal area, or a history of catheter associated urinary tract infection.
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 device have not been met. Therefore, we decided that the Plan does not have
to pre-approve a PUREWICK  external female urine collection device, for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869, 22870, and C1821), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this would provide significant clinical and quality of life benefits for the enrollee. The Plan denied your request. The Plan says there are not enough studies on Vertiflex Superion to show it is safe and effective.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertilfex device 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 surgery have not been met.
Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code(s): 22869, 22870, and C1821), for the enrollee
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. 
 
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 the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for lumbar spine surgery. Medical problems are stable. There are no complex nursing or rehabilitation 
needs. The patient does not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program.  

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 
patient 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.