Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from September 25, 2019, through October 1, 2019 with the reported principal diagnosis, A41.52, Sepsis due to pseudomonas.

You asked the Plan to pay for inpatient services provided from September 25, 2019, through October 1, 2019 with the reported principal diagnosis, A41.52, Sepsis due to pseudomonas. The Plan denied your request. The Plan says according to coding guidelines and the documentation in the medical record, this condition did not qualify for reporting as the principal diagnosis.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis, A41.52, Sepsis due to pseudomonas. 

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 inpatient services provided from September 25, 2019, through October 1, 2019 with the reported principal diagnosis, A41.52, Sepsis due to pseudomonas. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found the enrollee presented to the hospital with signs and symptoms of UTI, which was diagnosed and treated. The enrollee was admitted with confusion and elevated creatinine. Vitals were stable. Liver and platelets were within normal limits. The enrollee was alert and oriented. Sepsis due to pseudomonas infection was diagnosed as the primary diagnosis associated with the admission. According to the records provided, there was no direct signs of organ injury related to sepsis to justify this diagnosis in the setting of what appears to be an uncomplicated UTI. Therefore, the principal diagnosis of A41.52, Sepsis due to pseudomonas is not supported sufficiently in the medical records. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from September 25, 2019, through October 1, 2019 with the reported principal diagnosis, A41.52, Sepsis due to pseudomonas.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eye surgery to be provided by an out-of-network provider.
You asked the Plan to pre-approve eye surgery. You say that you are not confident with the network doctors. You say that you need this surgery done as quickly as possible. The Plan denied your request. The Plan says in-network providers are available.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve eye surgery to be provided by an out-of-network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the specimen collection and infectious agent detection by nucleic acid provided on August 13, 2020.
You asked the Plan to pay for the specimen collection and infectious agent detection. You say that you have no knowledge of enrollee coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 specimen collection and infectious agent detection by nucleic acid provided on August 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided from August 19, 2020, through September 2, 2020.

You asked the Plan to pay for the physical therapy. The Plan denied your request. The Plan says there is no authorization for these services.

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 did not pre-approve the physical therapy. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physical therapy provided from August 19, 2020, through September 2, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service and ground mileage provided on November 20, 2020.
You asked the Plan to pay for the ambulance service and ground mileage. You say that the ambulance transport was prior to the enrollee's hospice admission. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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 ambulance service and ground mileage provided on November 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve jaw reconstruction services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve jaw reconstruction services. You say that you would like to continue care with the provider you had seen previously. The Plan denied your request. The Plan says there are oral surgeons located within your health network available to meet your needs.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve jaw reconstruction services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a sensor (A9276), transmitter (A9277) and receiver (A9278) for use with a continuous glucose monitor.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says these are non-covered items.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that HCPCS A9276, A9277, and A9278 are not covered codes.

The requested monitor is coded in such a way that makes it statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a sensor (A9276), transmitter (A9277) and receiver (A9278) for use with a continuous glucose monitor.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870). You say that you have debilitating lower back pain. The Plan denied your request. The Plan says there is not enough medical proof that shows the safety and/or success of the Vertiflex when used for painful lumbar spinal stenosis.

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 insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870).

Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interlaminar spacer device remains 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 insertion of interlaminar/interspinous process stabilization/distraction device (22869, 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the four resin-based composites provided on November 24, 2020.
You asked the Plan to pay for the resin-based composites. You say that you would like to appeal these services. The Plan denied your request. The Plan says your benefit allowance has been exhausted.
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 max allowance amount of $1,000 per year for supplemental comprehensive dental services. The contract says that you are responsible for all costs over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the November 24, 2020 date of service and your annual maximum benefit has been exhausted. The Plan does not need to pay more than $1,000 for supplemental comprehensive dental services. Therefore, we decided that the Plan does not have to pay more for the four resin-based composites provided on November 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a balloon sinuplasty.

You asked the Plan to pre-approve these services. You say that you are having a lot of pain, your sinuses are plugged, having ear pain and feel very dizzy. The Plan denied your request. The Plan says that the record does not show you have chronic sinus infections.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. You have not been diagnosed nor have met the criteria for either recurrent acute sinusitis or chronic sinusitis. The computed tomography (CT) did not show typical findings associated with chronic sinusitis. You do not complain of typical symptoms of sinusitis in the documented note including facial pain or pressure, headache, purulent nasal discharge, change in smell. There is no documentation showing you have tried and failed standard medical management including sinus rinses, nasal sprays, or two or more courses of antibiotics. Our physician reviewer found that your 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 a balloon sinuplasty.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on April 27, 2020 and April 28, 2020.

You asked the Plan to pay for the laboratory services. You say that medically necessary services were provided in good faith and you are seeking consideration for the services rendered. The Plan denied your request. The Plan says network providers were available to perform the services.

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 laboratory services provided by an out-of-network provider on April 27, 2020 and April 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you have difficulty using your legs, you have broken ribs, and have heart issues. You state your wife is unable to care for you at home. The Plan denied your request. The Plan says the stay is not medically necessary.

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 a fall, dizziness, and trouble walking. 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 acute IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
You asked the Plan to pre-approve therapeutic CGM. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the records do not show frequent blood glucose testing of 4 or more times per day and 3 or more daily injections of insulin with dosage adjusted due to blood glucose testing.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64635, 64636).
You asked the Plan to pre-approve facet joint injections. You say that you are in pain without these injections. The Plan denied your request. The Plan says the record does not show that your previous injections provided sufficient relief.
The Plan must follow Medicare rules. Medicare rules say that subsequent therapeutic facet joint procedures at the same anatomic site are considered medically reasonable and necessary the previous facet joint procedure resulted in at least consistent 50% pain relief for at least three (3) months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living as compared to baseline measurement using the same scale. We looked at the file and Medicare rules. The records show that the previous facet joint injection you received did not provide at least 50% pain relief or improvement. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64635, 64636).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF from May 20, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need beyond the last covered date. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter you do not require the necessary services on an inpatient basis, in a SNF setting beyond the last covered date.
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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF from May 20, 2021, forward.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).

You asked the Plan to pre-approve Gelsyn-3. You say that the enrollee has tried and failed non-steroidal anti-inflammatory drugs, cortisone injections, physical therapy, and exercise. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for the requested agent.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 Gelsyn-3. Our reviewer says that the requested Gelsyn-3 is not shown to be currently medically necessary and reasonable. Our physician reviewer found the enrollee is noted to have bilateral knee osteoarthritis. A request has been made for Gelsyn-3, a hyaluronic acid injection, to treat the osteoarthritis. Our reviewer found that the Plan requires that other forms of hyaluronic acid injections be used. There is no evidence that the enrollee is allergic to or intolerant of these other forms of hyaluronic acid. There is no evidence that the enrollee has tried and not responded to these other forms of hyaluronic acid injections. Our physician reviewer also found that there is no documentation as to why these other forms of hyaluronic acid would not be expected to be safe and effective for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 (J7328).