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

We decided that the Plan does not have to pay for a selective catheter placement arterial system (36247), an
angiography, visceral, selective or supra selective (75726) and an angiography, selective, each additional vessel
(75774) provided June 1, 2021.
You asked the Plan to pay for codes 36247, 75726 and 75774. You say that the services provided were
medically necessary. The Plan denied your request. The Plan says the billed codes are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
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 36247, 75726 and 75774. Our reviewer says that the
billed codes are not supported for payment. Our reviewer found the medical records provided do not include
sufficient documentation to validate that a selective catheter placement arterial system; initial third order or
more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family was performed.
The medical records provided indicate 75726 and 75774 are inclusive to 37243 and was performed as part of
the standard of medical /surgical practice when performing 37243, and is not eligible for separate
reimbursement.
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 36247, 75726 and 75774 have not been met. Therefore, we decided that
the Plan does not have to pay for a selective catheter placement arterial system (36247), an angiography,
visceral, selective or supra selective (75726) and an angiography, selective, each additional vessel (75774)
provided June 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an occlusal guard - soft appliance, full arch (D9945).  You asked the Plan to pre-approve a mouth guard. You say that you would like the mouth guard to be covered. The Plan denied your request. The Plan says this dental item 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 an occlusal guard - soft appliance, full arch (D9945).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from December 20, 2020, to December 22, 2020.  You asked the Plan to pay for the services. You say that there should be reconsideration of the DRG adjustment. The Plan denied your request. The Plan says the DRG was adjusted.  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 . 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 services at issue in this case were not supported by the medical records. Our physician reviewer found ICD-10 A41.9 Sepsis, unspecified organism is not supported as a primary diagnosis for hospital services provided. In this case, a query would be made before billing services. Severe sepsis is documented during this hospital admission; however, documentation to support sepsis is not clear and consistent throughout the hospital admission. A severe sepsis/septic shock workflow form was included, and documents "suspected with question of pneumonia.) SIRS criteria (must have at least 2) documents a temperature within normal limit, heart rate within normal limit (on beta blocker) and respiratory rate of 21. The rest of this flow sheet is not filled in, and therefore, does not clearly support severe sepsis. Although documentation supports sepsis is suspected, documentation does not confirm sepsis as primary diagnosis, and a query should be made.   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 inpatient hospital services provided to the enrollee from December 20, 2020, to December 22, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the drug is not being requested as incident to physician's services.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B,
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be
brought to the office for administration. Since the medication does not represent an expense to the physician
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that
the Plan does not have to pre-approve Botox.
Benefits for these services 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: 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 admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 based on the documentation provided there is no evidence that the enrollee requires
services that are not currently available at the present setting where he is receiving care. The enrollee can
remain at the current setting until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing long term care needs.
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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bone grafting, dental implants and implant supported mandibular prosthesis.  You asked the Plan to pre-approve bone grafting, dental implants and implant supported mandibular prosthesis. You say that this service is medically necessary to improve your quality of life and allow you to eat more. The Plan denied your request. The Plan says routine dental benefits are not covered under your benefits and this service is not covered under your medical benefits.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve bone grafting, dental implants and implant supported mandibular prosthesis.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a permanent leadless pacemaker.

You asked the Plan to pre-approve leadless pacemaker. You say that the enrollee is at risk of losing life without approval of this service. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because a leadless pacemaker is not covered outside of an approved Coverage with Evidence Development (CED) study.

The Plan must follow Medicare rules. Medicare rules say that Medicare only covers leadless pacemakers through approved CED studies. 

We looked at the file and Medicare rules. The record does not show that this service is being requested through an approved CED study. Based on this information, we decided that Medicare rules for coverage of leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a permanent leadless pacemaker.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for insertion of non-tunneled centrally inserted central venous catheter (procedure code 36556) provided to the enrollee on June 30, 2021.
You asked the Plan to pay for the services. You say that the services are separate from the items provided by the facility and surgeon. The Plan denied your request. The Plan says procedure 36556 is considered inclusive to CPT code 93503.
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 36556 is "Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older." 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 says that the services at issue in this case were not supported by the medical records. Our reviewer found the provider reported central venous catheter was placed, during the same session that the surgery performed insertion of flow-directed catheter. The documentation does not include records to support both procedures performed during the same session. The
anesthesia report just documents this procedure was performed, and therefore billing separately from CPT 95303 cannot be justified. 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 not been met. Therefore, we decided that the Plan does not have to pay for insertion of non-tunneled centrally inserted central venous catheter (procedure code 36556) provided to the enrollee on June 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system, custom seat cushion, and
custom back cushion.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The requested items do not serve a purpose that is primarily medical in nature. Therefore, we decided that the
Plan does not have to pre-approve a power seat elevation system, custom seat cushion, and custom back
cushion.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request.
The Plan says rules for SNF care have not been met.
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 you were admitted for congestive heart failure exacerbation and had
coronary artery bypass grafting. 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. In
conclusion, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One 30 mg.

You asked the Plan to pre-approve Gel-One. You say that the requested drug is necessary. You also say that the enrollee previously tried Euflexxa. The Plan denied your request. The Plan says The Plan says that the enrollee has not tried and failed any of the preferred drugs, Orthovisc, Supartz FX, Durolane, Monovisc, and Synvisc-One.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Gel-One. Our reviewer says that the requested drug, Gel-One, is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternatives. Therefore, the reviewer also found that the step therapy criteria have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gel-One have not been met. Specifically, the file does not show that the enrollee has tried and failed any of the Plan's preferred step one alternatives. Therefore, we decided that the Plan does not have to pre-approve Gel-One 30 mg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
You asked the Plan to pre-approve a pneumatic compression device. You say that the item is medically
necessary. The Plan denied your request. The Plan says this is not covered for venous insufficiency.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily,
multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting,
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device
(E0652).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TriVisc.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have a
diagnosis of primary osteoarthritis of both knees. You have not tried and failed the Plan's required drugs,
Orthovisc, Synvisc, or Synvisc-One. The records do not show that the required drugs would have adverse
affects or be less effective; therefore, TriVisc is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve TriVisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wheelchair ramp for an automobile.
You asked the Plan to pre-approve wheelchair ramp. You say that this is medically necessary because you are unable to lift your current power scooter. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this ramp is not for use inside of your home, is useful in the absence of illness/injury, and does not serve a primarily medical purpose.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp for an automobile.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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 you were admitted for syncope, rib fractures, and flank hematoma. 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. In conclusion, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211), partial lower denture (D5214), crown (D2751) for tooth # 4, and oral exam (D0120).
You asked the Plan to pre-approve the dental services. You say that you need partial dentures so you can eat. You say that you are disappointed that the plan only covers diagnostic and preventive services. You also say that you do not have money to cover the cost for the partial dentures. The Plan denied your request. The Plan says partial dentures and crown are not listed as covered services. The Plan says 2 oral exams are covered per 12 months. The Plan also says the frequency limit has been exceeded.
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 partial dentures and crown are not among those covered under this benefit. Although oral exams are a covered service, the frequency limit of 2 per 12 months has been exceeded. The record shows that the Plan paid for oral exams that you received on June 19, 2021, and July 15, 2021. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5211), partial lower denture (D5214), crown (D2751) for tooth # 4, and oral exam (D0120).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the FoundationOne Liquid CDx testing provided on February 8, 2021.  You asked the Plan to pay for the services. You say that this is an FDA approved test and is helpful in therapeutic decision making. The Plan denied your request. The Plan says this is not approved for the enrollee's type of cancer.  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 based on the current medical literature, FoundationOne Liquid CDx is not considered medically reasonable and necessary for this enrollee's condition of metastatic melanoma.  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 the FoundationOne Liquid CDx testing provided on February 8, 2021.