Persius/hicric huggingface dataset:
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria  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 you do 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. While you may benefit from physical therapy, and occupational therapy, your rehab needs can be safely provided in an alternate and lower intensity setting such in a skilled nursing facility.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shingles vaccine (90750) provided on September 10, 2021.  You asked the Plan to pay for the shingles vaccine. You say that you would like this claim to be fully reimbursed. The Plan denied your request. The Plan says this vaccine is not covered by your medical benefit.  In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules.   Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine (90750) provided on September 10, 2021.   Benefits for the shingles vaccine 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded as 01380 provided on May 4, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed. The Plan denied your request. The Plan says this code is considered incidental to the procedure performed.  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 01380 is anesthesia for all closed procedures on knee joint.  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 the documentation does not support the claim as billed. Our reviewer found that the medical records provided do not include sufficient documentation to validate billing CPT 01380. Therefore, this service is not eligible for separate reimbursement, as it is included in the primary procedure.  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 services coded as 01380 provided on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded as 99100 provided on February 17, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says no separate payment is made per Medicare 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, the CPT Code Manual definition of code 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).  We looked at the file and Medicare rules. In this case, this claim has a Status Code of "B for Bundled Code. This means that payment for this service is always bundled into payment for other services not specified. 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 services coded as 99100 provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for neuropathy treatment services provided on August 12, 2021.  You asked the Plan to pay for medical services. You say that this service was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental and eligible for payment.  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 medical services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the services rendered are considered experimental/ investigational. Therefore, it is deemed 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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for neuropathy treatment services provided on August 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the radioactive tracer for identification of sentinel node (38792) provided on May 13, 2021.  You asked the Plan to pay for the radioactive tracer for identification of sentinel node. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT code 38792 and 38900  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 radioactive tracer for identification of sentinel node. Our reviewer says that CPT code 38792 does not meet criteria for billing or reimbursement consideration. Our reviewer found CPT 38792 has a bundled relationship with CPT 38900, which was performed during the same operative session on May 13, 2021.  A modifier is allowed to unbundle these services, providing the medical documentation supports the use of an appropriate modifier.  In this case, the medical records provided do not support the use of a 59 modifier on CPT 38792, therefore, no additional reimbursement is allowed for 38792 59 LT.  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 radioactive tracer for identification of sentinel node have not been met. Therefore, we decided that the Plan does not have to pay for the radioactive tracer for identification of sentinel node (38792) provided on May 13, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Praluent.  You asked the Plan to pre-approve Praluent. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.  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 Praluent.   Benefits for Praluent 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: 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 your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.  You asked the Plan to pre-approve RFA to the SI joint. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested procedure is considered experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve RFA to the SI joint. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the literature, sacral lateral nerve branch blocks and/or ablations/neurotomies for the diagnosis and/or treatment of sacroiliac joint mediated pain is considered experimental and investigational. Studies completed say that this procedure does not improve outcomes compared to standard treatment of SI joint pain. Radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary.  The review has determined that the requested SI joint RFA 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 RFA to the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) to the sacroiliac (SI) joint.
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 admission to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in an alternate 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 based on the documentation provided, the enrollee does not require the intensity of services provided in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met in a lower level of 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.
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 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 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 are no services available at the LTACH that you require 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 your diagnosis and condition 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 an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 an Intracept procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy for back pain treatment.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hernia repair procedure coded as 49561-59 provided on June 2, 2021.  You asked the Plan to pay for the hernia repair procedure. You say that the documentation supports separate payment for this code as billed with the -59 modifier. The Plan denied your request. The Plan says the documentation does not support the use of the -59 modifier to bypass the bundling edit.  The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    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 hernia repair procedure Our reviewer says that the documentation does not support the code as billed. Our physician reviewer found CPT 49561 has a bundled relationship with CPT 49562, which was performed on June 2, 2021, during the same operative session. However, a modifier is allowed to unbundle the relationship, providing the medical documentation supports the use of an appropriate modifier. In this case, the medical documentation provided does not include sufficient documentation to support the use of the -59 modifier and no additional reimbursement is allowed.  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 hernia repair procedure have not been met. Therefore, we decided that the Plan does not have to pay for the hernia repair procedure coded as 49561-59 provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96374) provided March 9, 2021.  You asked the Plan to pay for the injection services. You say that the physician documentation in the attached record supports treatment at the level of care billed. In the physician's professional judgment, the enrollee required services provided. The Plan denied your request. The Plan says procedure code 96374 exceeds the allowed number of units of 1 in 1 day. Procedure code J1031 processed according to the outpatient APC pricing as a packaged code with a zero allowable.  The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.  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 injection services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no documentation provided indicating that the additional billed unit was 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 injection services have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic, prophylactic, or diagnostic injection (specify substance or drug) (96374) provided March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex device.  You asked the Plan to pre-approve a Vertiflex device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a Vertiflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertiflex device is experimental. More research is needed to show safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA)of the head (70546) provided on August 26, 2021.  You asked the Plan to pay for the MRA services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier 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 70546 is a column II code to column I code 70553. 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 magnetic resonance angiography (MRA)of the head (70546) provided on August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left total hip arthroplasty.  You asked the Plan to pre-approve a left total hip arthroplasty. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 a left total hip arthroplasty. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of at least 6 weeks of recent physical therapy for left hip pain.  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 left total hip arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve a left total hip arthroplasty.