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

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the admission 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you have no complex wound care, new tube feedings, or other skilled nursing needs. You do not require skilled nursing services on a daily basis. Your functional level does not require skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crutch substitute.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the item is not covered.

The Plan must follow Medicare rules. Medicare rules say that a crutch substitute (E0118) is not medically necessary. 

We looked at the file and Medicare rules. The requested item is a crutch substitute described by procedure code E0118. This item is denied by Medicare as not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a crutch substitute.
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 early treatment at this acute level of care is most needed. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy program with multiple visits from a rehab doctor per week.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for pneumonia and a pulmonary embolism. Her medical problems are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device. You say that this requested device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the CardioMEMS device is experimental and investigational for heart failure and all other indications.
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 the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 63-year-old woman with non-ischemic cardiomyopathy, morbid obesity, ejection fracture=20% and New York Heart Association (NYHA) Class III symptoms while on maximally tolerated guideline directed medical therapy. In this case, the patient has severe heart failure with depressed ejection fracture and is on appropriate guideline directed congestive heart failure (CHF) medications with recurrent hospitalizations this past year for decompensated CHF. Management of her heart failure with standard medical therapy and relying on symptoms and signs has not been effective in keeping her with minimal symptoms and has resulted in acute hospitalizations. CardioMEMS device monitoring in this situation can provide additional heart filling pressure data to better manage very complex diuretic and vasodilator regimens. Data from the Champions trial along with longer term follow-ups studies have shown a significant decrease in hospitalizations and improvement in heart failure symptoms and NYHA Class with the use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use as well as reasonable patient selection criteria, and Food and Drug Administration approved indications all of which are met in this clinical instance. Given the severe symptoms of recurrent CHF (NYHA Class III) which appears very sensitive to volume loading conditions, complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational based on these data backed indications and would meet the medical reasonableness and necessity criteria. 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 CardioMEMS device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Coflex device.
You asked the Plan to pre-approve the Coflex device. You say that this requested item is medically necessary for the enrollee. The Plan denied your request. The Plan says published studies do not demonstrate any long-term health outcome advantage with the use of Coflex as an alternative to standard surgical treatment.
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 Coflex device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show safety and efficacy of the device.
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 Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Coflex device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the denervation procedures coded as 64612, 64642 and 64643 provided on April 19, 2021.
You asked the Plan to pay for the denervation procedures. You say that the documentation supports the procedure as billed. The Plan denied your request. The Plan says the documentation does not support the services 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 64612 is chemodenervation of muscles(s); muscle(s) innervated by facial nerve, unilater (eg, for blepharospasm, hemifacial spasm). The CPT Code Manual definition of code 64642 is chemodenervation of one extremity; 1-4 muscles(s). Finally, the CPT Code Manual definition of code 64643 is each additional extremity, 1-4 muscles(s) (List separately in addition to code for primary procedure) for reimbursement consideration. Healthcare plan denied payment for documentation does not support services billed.
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 denervation procedures. Our reviewer says that the medical records do not support the codes as billed. Our reviewer found the procedure reports giving Lidocaine (a numbing agent). Chemodenervation used a substance to block nerve signals that control muscles. Neurotoxin that stops nerves from releasing a chemical messenger - or transmitter - that tells muscles to contract, which results in muscle relaxation. In this case, CPT 64612, 64642 and 64643 are incorrect codes to report for lidocaine injections. 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 denervation procedures have not been met. Therefore, we decided that the Plan does not have to pay for the denervation procedures coded as 64612, 64642 and 64643 provided on April 19, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Tempus Solid Tumor testing rendered on April 8, 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 that the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that molecular pathology procedures are covered when specific 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 pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has Merkel cell carcinoma diagnosed March 8, 2021. The role of adjuvant treatment for locally advanced/node positive Merkel cell cancer it the ongoing subject of clinical trials. Molecular profiling of tumors helps aid in determining eligibility based on molecular profiling and can identify markers for later lines to therapy. NCCN Guidelines for Merkel cell strongly recommends enrollment in a clinical trial when available. The use of molecular profiling, such as with Tempus, was reasonable and medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for the Tempus Solid Tumor testing rendered on April 8, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation (E0730).
You asked the Plan to pre-approve the TENS device. You say that the one that you do have one that you received /11/2018, but it is not working anymore. The Plan denied your request. The Plan says the Plan has already provided a four lead TENS unit that serves the same purpose on 7/11/2018. Medicare does not pay for replacement equipment during the reasonable useful lifetime.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a four lead TENS Unit. The TENS Unit serves the same purpose as the TENS unit received on 07/11/2018. The Plan confirmed with the supplier that there were no calls from you to the supplier and there are no notes about the current TENS unit not working, malfunctioning or needing to be replaced. Therefore, we decided that the Plan does not have to pre-approve the transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation (E0730).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the computed tomography (CT) scan of the brain provided on April 23, 2021.
You asked the Plan to pay for the CT scan of the brain. You say that this procedure was medically necessary. The Plan denied your request. The Plan says that the medical necessity of the procedure was not supported.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 pay for the CT scan of the brain. Our reviewer says that the requested service was medically reasonable and necessary. Our physician reviewer found the history dictated as the indication for the CT of the brain of April 21, 2021 qualifies for the performance of a CT of the brain. Syncope, mechanical fall and weakness qualify as symptoms where a CT of the brain would be prudent and reasonable. 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 CT scan of the brain have been met. Therefore, we decided that the Plan has to pay for the computed tomography (CT) scan of the brain provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound closure provided on March 11, 2021, billed with code 12021.
You asked the Plan to pay for the wound closure. You say that this should be paid separately. The Plan denied your request. The Plan says this was correctly denied as inclusive to the primary procedure.
The Plan must follow Medicare rules. The rules say that when an NCCI edit exists between two codes, the Column 2 code is only payable when a clinically appropriate modifier is used. 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 coding 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 wound closure. Our reviewer says that the documentation does not support the use of modifier -59 to bypass this code pair edit. Our coding reviewer found documentation does not support a separate and distinct procedure was performed. A bursectomy and debridement was performed, with closure. A closure of a procedure is inclusive to the procedure itself and should not be reported separately. There is no evidence the wound closure was unrelated to the bursectomy. 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 wound closure have not been met. Therefore, we decided that the Plan does not have to pay for the wound closure provided on March 11, 2021, billed with code 12021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the Intracept procedure. You say that the records provided support that the requested service is medically necessary. The Plan denied your request. The Plan says review of the current medical literature indicates that the requested service is considered experimental and 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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental for low back pain. 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 the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies (CPT code(s): A4550, A4556, A4557, S1015 and S8301) provided to the enrollee on December 28, 2020.
You asked the Plan to pay for the diabetic supplies. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered 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. For Procedure Code For Procedure Code A4550, A4556 and A4557: Our records indicate that procedure A4550, which has a status indicator of 'B' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare. Our records indicate that procedure A4556 and A4557, which has a status indicator of 'P' on the CMS Physician Relative Value File, is always bundled into payment for other services not specified and no separate payment is made per Medicare. For Procedure Code S1015 and S8301: Medicare guidance says code HCPCS code S1015 and S8301 is assigned a status code = I. You can find this guidance in the 2020 National Physician Fee Schedule Relative Value File October Release. Therefore, we decided that the Plan does not have to pay for the diabetic supplies (CPT code(s): A4550, A4556, A4557, S1015 and S8301) provided to the enrollee on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided to the enrollee on May 3, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services rendered by non-participating providers require prior authorization.

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 an office visit provided to the enrollee on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on
December 15, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the nursing facility care. You say that the medical records provided support the
necessity for your provider to render services. 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 subsequent nursing facility care (99308)
provided on December 15, 2020 by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy (PT) services.
You asked the Plan to waive the copayment for the PT services. You say that you are on a fixed income and you will have multiple physical therapy visits each week, but the copay is kind of high. The Plan denied your request. The Plan says copayments are a fixed amount that the enrollee is responsible for and cannot be waived.
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 $30 for each Medicare covered physical therapy visit. You have been asked to pay $30 for each physical therapy visit. The PT services falls within the Outpatient rehabilitation services benefit category. 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 physical therapy (PT) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve the requested item. You say that you have trouble getting in and out of the bathtub. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.