Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromonitoring services provided on July 25, 2021.

You asked the Plan to pay for the neuromonitoring services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says third party vendors are not payable.

The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. 

We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during an inpatient hospitalization. Payment for these services were included in the facility payment. Based on this information, we decided that Medicare rules for coverage of the neuromonitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the neuromonitoring services provided on July 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the placement of a soft tissue localization device (10035) provided on September 15, 2021.  You asked the Plan to pay for the placement of a soft tissue localization device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 10035 is placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion.   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 placement of a soft tissue localization device. Our reviewer says that CPT code 10035 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that 10035 59 was performed on September 15, 2021 as a distinct/separate procedure, therefore this procedure cannot be verified.  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 placement of a soft tissue localization device have not been met. Therefore, we decided that the Plan does not have to pay for the placement of a soft tissue localization device (10035) provided on September 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (19371) 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 the member does not have any condition for coverage of these services.    The Plan must follow Medicare rules. Medicare rules say that removal or revision of a breast implant can be covered if Medicare criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The enrollee has previously had silicone breast implants and wishes alteration of appearance. The record does not indicate the presence of an enumerated condition for which the requested service is covered. 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 Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents (19371) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you do not require daily skilled nursing services on an inpatient basis.  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. Continued SNF services beyond February 13, 2022, were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that you were admitted to a SNF after treatment in an acute hospital for third degree burns. You are reported to be non-ambulatory at baseline. You remain non-ambulatory and were dependent for transfers. You were at a moderate to dependent assist level for most activities of daily living. There is no documentation that you require skilled nursing services of a skilled professional nurse to provide medically necessary treatment. Your ongoing burn treatments with Silvadene dressings twice daily do not appear to skilled treatments. You do not require skilled therapy services of a qualified therapist to provide treatment. You have made no meaningful progress with therapy thus far. Therefore, you do not require daily skilled services 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulation (PNS) system  You asked the Plan to pre-approve Sprint PNS system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 Sprint PNS system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic bilateral foot pain due to chronic bone infarctions. The enrollee has tried non-steroidal anti-inflammatory drugs (NSAIDs), Physical therapy, home exercise program, and steroid injections. The enrollee is taking Lyrica, Tizanidine, and Celebrex. The request would be considered experimental/ investigational for the treatment of this chronic pain state. Therefore, the enrollee does not meet criteria for the requested services.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Sprint PNS system have not been met. Therefore, we decided that the Plan does not have to pre-approve Sprint peripheral nerve stimulation (PNS) system
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the selective catheter placement (36215) and angiography (75710) provided on June 24, 2021.  You asked the Plan to pay for the selective catheter placement and angiography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services 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 36215 is selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family.  The CPT Code Manual definition of code 75710 is angiography, extremity, unilateral, radiological supervision and interpretation.  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 selective catheter placement and angiography. Our reviewer says that CPT codes 36215 and  75710 do not meet criteria for billing or reimbursement consideration. Our reviewer found the procedure report does not include enough documentation to confirm access. The report describes a fistulagram was performed, then inflow.  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 selective catheter placement and angiography have not been met. Therefore, we decided that the Plan does not have to pay for the selective catheter placement (36215) and angiography (75710) provided on June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003RR).  You asked the Plan to pre-approve a lightweight wheelchair. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 lightweight wheelchair. Our reviewer says that the item is not medically necessary. Our physician reviewer found there is no clear documentation that this patient has a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the home.      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 lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003RR).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an evaluation and extraction to be provided by an oral surgeon.  You asked the Plan to pre-approve the evaluation and extraction. The Plan denied your request. The Plan says dental services are only covered when they are performed by a participating general dentist. The Plan also says that dental services performed by an oral surgeon are not covered.  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 covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve an evaluation and extraction to be provided by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be improving and stable and only requires short-term additional acute care services that can safely be administered at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed.    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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device (E0601), filter (A7039, A7038), nasal interface (A7034), headgear (A7035), and mask wipes (E1399), provided on January 21, 2021, through September 10, 2021.

You asked the Plan to pay for the CPAP device and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says you obtained these items through a provider that is not enrolled in Medicare.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a continuous positive airway pressure (CPAP) device (E0601), filter (A7039, A7038), nasal interface (A7034), headgear (A7035), and mask wipes (E1399), provided on January 21, 2021, through September 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  

You asked the Plan to pre-approve foot orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.  

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    

Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.

You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is still considered 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
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 an admission to an IRF is medically necessary. The Plan denied your request. The Plan says the care needed can be provided in a skilled nursing level of care at this time.  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 at the current functional level and activity tolerance, the enrollee will not be able to tolerate or make a significant functional progress in a reasonable period of time as expected 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the coronavirus vaccine provided on August 10, 2021.  You asked the Plan to pay for the coronavirus vaccine. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this is covered by Original Medicare as the enrollee was in hospice care at the time.    Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the coronavirus vaccine provided on August 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on April 26, 2021.  You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on April 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the individual psychotherapy (90832) provided on May 10,2021 to September 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the psychotherapy services. You say that you have been seeing this provider for about 5 years. You have an ongoing relationship with this provider and do not want to have to start over with a new provider. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the individual psychotherapy (90832) provided on May 10,2021 to September 21, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the nasal/sinus endoscopy (31257) provided on May 26, 2021.  You asked the Plan to pay for the nasal/sinus endoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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.  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 nasal/sinus endoscopy. Our reviewer says that CPT code 31275 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include sufficient documentation to validate that a Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including sphenoidotomy was performed on May 26, 2021, therefore this procedure cannot be verified.  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 nasal/sinus endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy (31257) provided on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left atrial appendage closure procedure.  

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the clinical notes do not indicate the enrollee is unable to take long-term oral anticoagulation.  

The Plan follows Medicare rules. Medicare rules say that a left atrial appendage closure is only covered under certain medical indications.   

The file shows that a Watchman device was requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the requested services. Our physician reviewer found that the enrollee has an elevated risk of thromboembolic stroke due to atrial fibrillation and high CHADS2VASC score. There is no contraindication to anticoagulation according to the physician. As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or medically necessary in the clinical management of this patient.  

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a left atrial appendage closure procedure.