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

We decided that the Plan does not have to pay for the anesthesia for intracranial procedures (00211) provided on June 16, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the correct anesthesia code to report for 61154 is 00214 which has a base value of 9.

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 00211 is anesthesia for intracranial procedures; craniotomy or craniectomy for evacuation of hematoma. 

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 anesthesia services. Our reviewer says that CPT code 00211 does not meet criteria for billing or reimbursement consideration. Our reviewer found a healthcare professional shall not upcode, downcode, unbundle, fragment or report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes the services. There is a more appropriate anesthesia code to bill with CPT code 61154. 

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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for intracranial procedures (00211) provided on June 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-emergency transportation to a doctor's appointment.

You asked the Plan to pre-approve non-emergency transportation to a doctor's appointment. You say that you are unable to walk and experiencing paralysis. The Plan denied your request. The Plan says a physician's office is not a covered destination.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 non-emergency transportation to a doctor's appointment. Our reviewer says that non-emergency ambulance transportation is not medically necessary. Our physician reviewer found that in this case, the record indicates that the requested service is transport to a physician's office. The record indicates that the enrollee is total assist secondary to recent acute ischemic stroke. The record does not indicate that the enrollee's clinical condition is such that other methods of transport are contraindicated. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of non-emergency ambulance transportation to a doctor's appointment have not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation to a doctor's appointment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).

You asked the Plan to pre-approve the home ventilator. You say that the DME is necessary. The Plan denied your request. The Plan says a home mechanical ventilator with settings that could be delivered by bilevel positive airway pressure (BiPAP) with average volume-assured pressure support (AVAPS) for you is not covered.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 home ventilator. Our physician reviewer found the Life2000 system is not medically necessary. This system is not a true ventilator, because it is not capable of providing full ventilatory support. It is meant to be used during activity, not sleep. There is inadequate evidence that it is beneficial in any lung condition. You do not meet criteria for a home ventilator. You do not have a covered diagnosis: chronic obstructive pulmonary disease (COPD), thoracic restrictive disease, neuromuscular disease. There is no evidence of nocturnal hypoventilation, with an arterial blood gas (ABG) showing carbon dioxide (CO2) retention. The denial is upheld. 

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) stay.

You asked the Plan to pre-approve the SNF stay. You say that you would like to appeal this service. The Plan
denied your request. The Plan says that this request 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 the SNF stay. Our reviewer says that
you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily
skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional
nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill,
knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not
require daily skilled nursing and/or skilled therapy on 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 the SNF stay have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in another setting.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sacral ulcers and osteomyelitis. 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 the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
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 would like reconsideration because you require IRF care and still need medical assistance. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the requested IRF care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.Your 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. There is no documentation of a need for an intensive 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF services are medically necessary. The Plan
denied your request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF.

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 based on review of the available records the enrollee has debility from acute
illness and is stable with no other acute medical issues and does not meet CMS coverage criteria for an IRF
admission. With her current medical stability, there is no need for physical medicine and rehabilitation
physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute
exacerbations of chronic medical conditions. There are no acute rehabilitation nursing needs noted in the
record. The enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day, at least
5 days per week with multidisciplinary approach to daily therapy. Her therapy needs can be easily and safely
provided in a skilled nursing facility (SNF) setting. An IRF admission is not medically necessary based on lack
of medical complexity and nursing needs. The document does not support the necessity for admission to and
IRF. While the enrollee may benefit from continued physical therapy (PT), and occupational therapy (OT), her
rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF.

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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.

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 self-administered drugs are not covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second diagnostic facet joint procedure (64493,
64494).

You asked the Plan to pre-approve a second diagnostic facet joint procedure. You say that this is medically
necessary. The Plan denied your request. The Plan says the requirements for coverage have not been met.

The Plan must follow Medicare rules. Medicare rules say that a second confirmatory diagnostic facet joint
procedure is considered medically reasonable and necessary if the first diagnostic facet joint procedure, there
was a consistent positive response of at least 80% relief of primary (index) pain (with the duration of relief
being consistent with the agent used).

We looked at the file and Medicare rules. The records show that the enrollee's previous procedure provided
only 30 to 40% pain relief. Based on this information, we decided that Medicare rules for coverage of a second
diagnostic facet joint procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve
a second diagnostic facet joint procedure (64493, 64494).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740) provided on September 2, 2021.  You asked the Plan to pay for the crown. You say that you would like to appeal this service. You also say that the toot was weakened and severely worn down. The Plan denied your request. The Plan says the $383 member liability applied correctly to your liability per the Evidence of Coverage.  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 Plan offers a $0 copay up to the $2,000 allowance for all covered dental services. The contract says that you pay 100% of charges beyond the $2,000 allowance. The record shows that you met the annual maximum benefit while processing this claim for the September 2, 2021 date of service and your annual maximum benefit has been exhausted Therefore, we decided that the Plan does not have to pay for the crown (D2740) provided on September 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.

You asked the Plan to pre-approve the accessories. 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. 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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has three power options of tilt, recline, and power elevating leg rests but the enrollee's right upper extremity strength and function support that the enrollee can control any power options through their own switches. 

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 accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve additional power wheelchair accessories (E2311, E2313, E2377) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage services coded 93226 provided on July 15, 2021.  

You asked the Plan to pay for the external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 code 93226 is external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage; scanning analysis with report.   

We find that CPT code 93226 is not supported in the medical record. Specifically, the provider reported an external electrocardiographic scanning component that is only reportable once every 48 hours which was previously reported within two days. This code is only reportable once every 48 hours. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage services have not been met. Therefore, we decided that the Plan does not have to pay for the external electrocardiographic recording up to 48 hours by continuous rhythm recording and storage services coded 93226 provided on July 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Ability Drive feature (K0108) for a power wheelchair.  You asked the Plan to pre-approve the Ability Drive feature. You say that the feature is medically necessary. The Plan denied your request. The Plan says this function is experimental and non-covered.  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 Ability Drive feature. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found this control software (Ability Drive) does not have FDA approval at this time and would be considered experimental until it does. There is insufficient research to support the safety and efficacy of this feature at this time.  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 Ability Drive feature have not been met. Therefore, we decided that the Plan does not have to pre-approve an Ability Drive feature (K0108) for a power wheelchair.
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 a study like (similar to) the one requested has already been approved for the enrollee. The Plan states an approval letter (separate letter) has been sent to the enrollee. The Plan states they need results of the prior approved study that show the need for repeat imaging or the enrollee's doctor must confirm that the prior approved study was not performed.

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 the record indicates that the enrollee underwent a CT scan due to having a palpable posterior back lesion bit no CT scan correlated was identified. There are no other records.to review. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 

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.