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

 We decided that the Plan has to pay for the percutaneous closure transcatheter left atrial appendage (33340) provided on March 26, 2021.  You asked the Plan to pay for the percutaneous closure transcatheter left atrial appendage. You say that these services were medically reasonable and necessary. The Plan denied your request. The Plan says that this claim does not meet standards of claim coding.  The Plan follows Medicare rules. Medicare rules say that the criteria for coverage for the LAAC device listed in the Medicare rules section must be met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the percutaneous closure transcatheter left atrial appendage. Our reviewer says that the requested services were medically reasonable and necessary based on Medicare coverage criteria. Our physician reviewer found 66-year-old woman with history of chronic atrial fibrillation for which left atrial appendage closure device (LAAC) authorization implantation is requested. She has a history of a cerebral aneurysm and intra-cerebral hemorrhage requiring craniotomy. She is reported to have a 'high' CHADS2VASC score reflecting a high risk for thromboembolic stroke for which chronic oral anticoagulation (OAC) is required, yet contraindicated because of her aneurysm and intracerebral hemorrhage.   At issue is the medical necessity of implanting a LAAC device in this patient in whom there is elevated risk of thromboembolic stroke due to her atrial fibrillation and high CHADS2VASC score, coupled with a contraindication for chronic OAC because of previous intracerebral hemorrhage from a brain aneurysm and consequent craniotomy. While supportive medical records could be requested for detailed clinical documentation--for example defining the basis for her "high" CHADS2VASC score--it appears that this patient was a suitable candidate for LAAC treatment based on current guidelines. 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 percutaneous closure transcatheter left atrial appendage have been met. Therefore, we decided that the Plan has to pay for the percutaneous closure transcatheter left atrial appendage (33340) provided on March 26, 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits.  You asked the Plan to pre-approve home health physical therapy visits. You say that these services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for home health physical therapy services have not been met.  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 home health physical therapy visits. Our reviewer says that the requested home health physical therapy services are not medically reasonable and necessary. Our physician reviewer found based on the documentation provided the enrollee does not have documented, ongoing, home health physical therapy service needs. The enrollee is functioning at a level commiserate with a lower level of care.  As such, the requested, ongoing, home health physical therapy 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 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional home health physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the services of a licensed massage therapist (LMT).  You asked the Plan to pre-approve the LMT services. You say that you feel that this should be covered because the LMT works out of your doctor's office and has been approved for Medicare coverage before. You believe that this is clearly a medical treatment which is helpful for your medical condition. The Plan denied your request. The Plan says the requested services are not covered by Medicare.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve the services of a licensed massage therapist (LMT).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the echocardiography services (93308) provided on  April 13, 2021.  You asked the Plan to pay for the echocardiography services. You say that you would like this claim reprocessed and approved for payment based on the medical records. The Plan denied your request. The Plan says an appropriate modifier was not used as required by Medicare rules.  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 93308 is a column II code to column I code 33362. 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 echocardiography services (93308) provided on  April 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the intravenous infusion (96365) and the hepatic function panel (80076) provided on January 17, 2021.  You asked the Plan to pay for codes 96365 and 80076. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 96365 is a column II code to column I code 74177. This claim has not been billed with an appropriate modifier to bypass the edit. We have also confirmed that code 80076 is a column II code to column I code 80053, and no modifier is allowed to bypass this 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 intravenous infusion (96365) and the hepatic function panel (80076) provided on January 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve brow lift repair for the enrollee.  You asked the Plan to pre-approve the services. You say that the records provided support the need for the requested services. The Plan denied your request. The Plan says the clinical records do not support that the requested services are medically necessary.  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 servfices. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it has not been demonstrated that brow ptosis repair is necessary in addition to bilateral blepharoptosis repair for an adequate functional result.  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 servfices have not been met. Therefore, we decided that the Plan does not have to pre-approve brow lift repair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (procedure code 87088 x 1 unit) provided to the enrollee on April 9, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not submit progress notes that are needed in order to determine the clinical utility of the testing.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record provided are insufficient to establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure code 87088 x 1 unit) provided to the enrollee on April 9, 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 the criteria for admission to an LTACH are not met. The enrollee's status is stable and improving at the time of this request, and they are receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which the LTACH may offer a therapeutic advantage.  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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Mohs Micrographic surgery.  You asked the Plan to pre-approve Mohs Micrographic surgery. 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 follows Medicare rules. Medicare rules say that Mohs Micrographic Surgery is indicated only when the superficial (lateral) or deep margins of the cancer lesion are uncertain clinically AND the likelihood of surgical cure and reconstruction would be compromised without use of immediate microscopic examination of the surgical margins.  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 Mohs Micrographic surgery. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of Mohs Micrographic Surgery is not considered medically reasonable and necessary for squamous cell primary in situ squamous cell carcinoma less than or equal to 2 cm in healthy patients.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Mohs Micrographic surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Mohs Micrographic surgery.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 70544) provided to the enrollee on November 4, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says no documentation was received for this claim.  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 70544 is a column II code to column I code 70551. 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 imaging services (procedure code 70544) provided to the enrollee on November 4, 2020.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 the enrollee appears somewhat unstable still and requires additional short-term acute care services that can be safely administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has been completed and the enrollee is more stable.    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 pre-approve a computed tomography (CT) scan.  You asked the Plan to pre-approve a CT scan. The Plan denied your request. The Plan says Medicare does not cover a screening for asymptomatic patients.  The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary.   The file shows that a CT scan of the heart with quantitative evaluation of coronary calcium was requested. 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 a CT scan. Our physician reviewer found that you have a history of hyperlipidemia. The calcium scoring appears to be ordered for risk stratification. Medicare does not cover a screening CCTA for asymptomatic patients, for risk stratification or for quantitative evaluation of coronary calcium. The review has determined that the requested CT scan 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 a CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for coronavirus testing received on January 2, 2021,  January 11, 2021, and January 18, 2021.  You asked the Plan to pay for the testing. You say that the plan is not in compliance with federal mandates. The Plan denied your request. The Plan says this is not a coverable benefit when done as screening for employment reasons.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay for services that are done for employment purposes.     The plan does not cover this testing when done to maintain employment. Therefore, we decided that the Plan does not have to pay for coronavirus testing received on January 2, 2021, January 11, 2021, and  January 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an osteogenesis stimulator.  You asked the Plan to pre-approve the stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  The Plan must follow Medicare rules. The rules say that an electrical bone stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.   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 stimulator. Our reviewer says that the requested stimulator is not medically reasonable or necessary. Our physician reviewer found detailed documentation is not evident regarding non-healing fracture on serial radiographs. The examinations provided document healing fracture supported by x-ray findings until 10/21/21 (when it is noted to be a non-healing fracture without imaging studies provided to support same). 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 electric (osteogenesis) bone growth stimulator 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 stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an osteogenesis stimulator.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health physical therapy visits.  You asked the Plan to pre-approve home health visits. You say that on reevaluation, the enrollee continues to show imbalance and hip weakness. The Plan denied your request. The Plan says the denial of authorization for continued home health skilled care visits is correct.  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 home health visits. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested home health care. Our physician reviewer found the enrollee does not have documented skilled therapy needs. The enrollee is functioning at a level commensurate with a lower level of care such as a home exercise program or outpatient therapy. Ongoing home health physical therapy services are not medically reasonable and necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that services can be provided at lower level of care such as home with home health.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.