Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve ablation of malignant prostate tissue, transrectal, with high
intensity-focused ultrasound (HIFU), Including ultrasound guidance (55880) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that that the member does not have recurrent prostate cancer.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. High Intensity Focused
Ultrasound (HIFU) ablation of the prostate is neither experimental nor investigational and is medically
reasonable and necessary for the enrollee. HIFU was FDA approved for prostate gland ablation October 9,
2015. HIFU of the prostate (CPT 55880) has Medicare coverage as of July 1, 2017. Numerous clinical studies
cited have demonstrated treatment efficacy that is comparable to surgery or radiation but with a much lower
risk of side effects such as impotence, incontinence and bowel injury. Our physician reviewer found that the
enrollee's condition meets Medicare criteria for these 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 these services have been met. Therefore, we decided that the Plan has to preapprove
ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU),
Including ultrasound guidance (55880) for the enrollee.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at 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. The
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for critical limb
ischemia and compartment syndrome and had an above the knee amputation. The enrollee's 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 patient has a need for physical and/or occupational therapy, there is no
documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on August 26, 2021, by an OON
provider.
You asked the Plan to pay for the services provided. You say that it is the nursing facilities responsibility to get
authorizations. The Plan denied your request. The Plan says the services were not urgent, emergent, or
approved in advance.
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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the rest home visit provided on August 26, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Coflex interspinous stabilization device
for the enrollee.
You asked the Plan to pre-approve these services. You say that this is a proven treatment option for spinal
stenosis. The Plan denied your request. The Plan says that a review of the current medical literature indicates
that this service is considered experimental and investigational as it is not identified as widely used and
generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature
published in the English language.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Coflex is an
implanted interlaminar stabilization device. There is insufficient evidence that the Coflex device is medically
reasonable and necessary in this setting. Our physician reviewer found that the enrollee's condition does not
meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve placement of a Coflex interspinous stabilization device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), anesthetic agent(s) and/or steroid;
transforaminal epidural (epidural steroid injections (ESI) - (CPT code(s): 64483 and 64484), for the enrollee.
You asked the Plan to pre-approve the services. You say that you are recommending this injection at this time.
The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's
records do not demonstrate significant improvement from previous epidural steroid injections (ESIs).
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 physician reviewer
found there is no documentation of improvement from the prior epidural injections. Therefore, the request is
considered 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural (epidural steroid
injections (ESI) - (CPT code(s): 64483 and 64484), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a receiver, transmitter, and sensor.
You asked the Plan to pre-approve a receiver, transmitter, and sensor. 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. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 a receiver, transmitter, and sensor. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided and details in the Local Coverage Determination (LCD): Glucose Monitors - L33822 and the Local Coverage Article: Glucose Monitor Policy Article - A52464, the A9278 receiver (monitor), external; A9277 transmitter, external and A9276 sensor, invasive, disposable do not meet Medicare criteria for coverage
as they are statutorily non-covered as they do not meet the definition of durable medical equipment. 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 receiver, transmitter, and sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve a receiver, transmitter, and sensor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (99204, 93005) provided on August 3,
2021.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed for
payment. The Plan denied your request. The Plan says the diagnosis is not appropriate for the enrollee's age
group.
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 medical services. Our reviewer says that the
documentation does not support payment for the services billed. Our reviewer found the diagnosis submitted
for the rendered services was F98.8 defined as Other specified behavioral and emotional disorders with onset
usually occurring in childhood and adolescence for services provided. In this case, the medical records do not
support this diagnosis.
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 (99204, 93005) provided on August 3, 2021
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Stereotactic computer-assisted (navigational) procedure (61783) and the Fluoroscopy (76000) provided on June 24, 2021.  You asked the Plan to pay for codes 61783 and 76000. You say that the medical records support the billing of codes 61783 and 76000 provided on June 24, 2021. The Plan denied your request. The Plan says the medical records do not support the billing of codes 61783 and 76000 provided on June 24, 2021.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 61783 is Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure). The definition of code 76000 is Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time.  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 61783 and 76000. Our reviewer says that the medical records do not support the billing of codes 61783 and 76000 provided on June 24, 2021. Our reviewer found the documentation submitted was reviewed and Medicare billing criteria have not been met. For code 61783, the operative report does not include enough information to confirm a computer was used to assist with coordinate determination established with a CT or MRI scan. For code 76000, reporting this service as a distinct procedure is not supported by the documentation, as this procedure would be performed with a lumbar arthrodesis and therefore, billing both would be considered services unbundled.  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 61783 and 76000 have not been met. Therefore, we decided that the Plan does not have to pay for the Stereotactic computer-assisted (navigational) procedure (61783) and the Fluoroscopy (76000) provided on June 24, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided
on September 13, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.
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 a $90
copayment for each emergency care visit.
You have been asked to pay a $90 copayment for the emergency care visit provided. This means that you have
been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the emergency room visit (99285) provided on
September 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 home health skilled nursing visits.
You asked the Plan to pre-approve 3 home health skilled nursing visits. 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 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 3 home health skilled nursing visits.
Our reviewer says that the services are not medically necessary. Our physician reviewer found recent notes
showing increased risks again or change in clinical status was not provided to justify additional home health
care. Therefore, this request for such will be considered not 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 3 home health skilled nursing visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve 3 home health skilled nursing 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 there is no expectation of functional improvement in reasonable time.
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
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and
does not require transfer to an 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. The enrollee
was admitted bronchiolitis obliterans organizing pneumonia. The record indicates that the enrollee continues to
have pneumonia and requires ongoing acute care services. The enrollee continues to receive acute care
services, and these have not been denied. The medical record does not indicate that the enrollee requires
services that he is not currently receiving but that would be available at the LTACH facility. Our physician
reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain/head.  You asked the Plan to pre-approve a PET scan of the brain/head. 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 an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease (AD) and Frontotemporal disorders (FTD).  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 PET scan of the brain/head. Our reviewer says that the services are not medically necessary. Our physician reviewer found the notes provided for review did not indicate that such a clinical situation was present in this enrollee's case. The provider's notes indicated that the PET/computed tomography (CT) scan was ordered primarily to evaluate for possible Alzheimer's. There was no indication of a suspicion of FTD. Nor was there a need to differentiate between AD and FTD. In as much this service would not meet the NCD's requirements for coverage.       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 PET scan of the brain/head have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain/head.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for debridement of nail(s) by any method(s); 6 or more (CPT code 11721)
provided on June 30, 2021.
You asked the Plan to pay for the service. You say that you would like coverage for podiatry services because
you will have to pay $55 for each visit and you thought you had a $35 copayment for each visit. The Plan
denied your request. The Plan says that your physician indicated in the notes that you are not overweight and
have diabetes but no peripheral neuropathy or vascular disease, and that your feet look good. The Plan states
Medicare would also require evidence of mycosis of the toenail (infection or disease caused by a fungus) and
marked limitation of ambulation (walking), pain, or secondary infection resulting from the thickening and
dystrophy (abnormality) of the infected toenail plate; therefore, their Medical Director determined that the
Medicare LCD criteria are not met in your clinical scenario.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. It appears that the plan's contracted delegate did not forward the appropriate
records for this service and has failed to forward them to support the decision to deny based on LCD criteria.
Therefore, we decided that the Plan has to pay for debridement of nail(s) by any method(s); 6 or more (CPT
code 11721) provided on June 30, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on August 13, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that the appropriate DEX Z-Code must be billed
adjacent to the CPT code for GeneSight testing.
We looked at the file and Medicare rules. The file shows that the claim was not billed with the required DEX
Z-Code. 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 pay for the GeneSight testing rendered on
August 13, 2021.