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

We decided that the Plan does not have to pay for the laboratory services (88312, 88313 and 88305) provided
on June 26, 2020, by an OON provider.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because
these services were provided in good faith to the member. The Plan denied your request. The Plan says the outof-
network services were not urgent, emergent or approved in advance.

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 laboratory services (88312, 88313 and 88305)
provided on June 26, 2020, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99336) provided on December 24, 2020 by an out of network (OON) provider.

You asked the Plan to pay for the domiciliary or rest home visit. You say that since the enrollee was in an assisted living facility, the doctor was not responsible to get authorization. The facility is responsible to obtain authorization which should cover medical treatments by the 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 established patient domiciliary or rest home visit (99336) provided on December 24, 2020 by an out of network (OON) provider.
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 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 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 do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your current medical
condition does not require intensive physician or nursing supervision in an IRF. You may benefit from
additional physical and occupational therapy, but the documentation does not reveal that this therapy must be
only on an intensive level 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 anesthesia services coded 01630 provided on December
3, 2020.

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 01630 is anesthesia for open or surgical arthroscopic
procedures on humeral head and neck, sternoclavicular joint, acromioclavicular joint, and shoulder joint; not
otherwise specified.

We find that CPT code 01630 is not supported in the medical record. Specifically, 100 units of this service were billed. The documentation does support that anesthesia was provided but does not support 100 units. 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 01630 provided on December 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional physical therapy visits.

You asked the Plan to pre-approve the additional visits. You say that this is medically necessary to continue your progress and prevent impairments that could lead to significant functional deficits. The Plan denied your request. The Plan says skilled treatment is not needed to maintain function.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided, there is no documentation that the requested therapy is generally accepted as specific and effective therapy for your condition. You appear to have essentially plateaued with skilled therapy. Further skilled therapy at this point does not appear likely to be able to achieve any significant improvement in symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. 

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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on December 2, 2020.

You asked the Plan to pay for the eye refraction. The Plan denied your request. The Plan says eye refractions outside of the annual supplemental routine eye exam are not covered.

Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that you had an eye refraction on September 11, 2020. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on
December 2, 2020.
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 enrollee requires long term acute care. The Plan denied your request. The Plan says the criteria for LTACH admission are not 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 the enrollee was readmitted with sepsis following an acute care hospital stay from COVID-19 and an anoxic brain injury. The enrollee is not clinically stable having anemia, pleural effusion, and ongoing seizure activity on EEG. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.

You asked the Plan to pre-approve the proton beam radiation therapy. You say that the requested treatment is
medically necessary. The Plan denied your request. The Plan says there is no current research showing that the
enrollee's type of cancer responds better to the requested type of treatment than intensity-modulated radiation
therapy.

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 proton beam radiation therapy. Our
reviewer says that proton beam radiation therapy is not considered medically reasonable and necessary in this
case. Our physician reviewer found any potential benefit or detriment of proton therapy over standard intensitymodulated
radiation therapy (IMRT) is an investigational question. To date, there are no compelling data to
suggest that proton therapy is superior to or more beneficial than IMRT/image-guided radiation therapy
(IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on
clinical trials, and to not routinely offer it to patients.

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 proton beam radiation therapy have not been met. Therefore, we decided
that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 100 additional non-emergent trips.

You asked the Plan to pre-approve the additional trips. You say that you need additional trips to be approved for coverage. The Plan denied your request. The Plan says only sixty (60) one-way transportation trips are offered per calendar year.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of up to 60 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. The record shows that zero (0) one-way transportation trips have been exhausted. You have sixty (60) one-way transportation trips remaining for the 2021 calendar year. Therefore, we decided that the Plan does not have to pre-approve 100 additional non-emergent trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT code 0275T).

You asked the Plan to pre-approve the services. You say that you do not want to have full surgery and have tried steroids and do not want to live in pain for the rest of your life. The Plan denied your request. The Plan says medical studies have not proven that the device(s) is helpful for treatment for the enrollee's health problem.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The medical necessity coverage criteria is not met since you are not participating in an approved clinical study. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar (CPT code 0275T).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation (90791) provided
October 29, 2020.

You asked the Plan to pay for the psychiatric evaluation. You say that you are not the custodian of records. The
facility may have already attached your medical records with their documentation. This appeal should be
granted because the services provided were medically necessary. The Plan denied your request. The Plan says
there is insufficient medical documentation to corroborate that the Medicare coverage criteria has been met.

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 90791 is psychiatric diagnostic evaluation.

We find that CPT code 90791 is not supported in the medical record. Specifically, all providers are required to
furnish necessary information to the health plan when requested. With the information provided, the plan is
unable to determine if a physician's order was given, the referring provider, how the enrollee came to this
provider, or if the services are necessary. The plan had made multiple attempts to obtain additional information
without success. Based on this information, we decided that Medicare rules for coverage of the psychiatric
evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the psychiatric
diagnostic evaluation (90791) provided October 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical necessity for you. The Plan denied your request. The Plan says rules for LTACH care have 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 your diagnosis and condition. 

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 that there is no documentation provided necessitating admission to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve portable oxygen concentrator. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the enrollee was already provided with a home oxygen system including portable tanks, and there is no documentation that this equipment is not satisfying the enrollee's oxygen needs within the home.

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 rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The file shows that the enrollee has a home oxygen system with portable tanks. This home oxygen system with portable tanks serves the same purpose as portable oxygen concentrator for use within the home. Medicare does not cover a portable oxygen concentrator for the purpose of travel outside of the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
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 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 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 enrollee does not require the intensity of services provided at an IRF.

Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the enteral nutrition supplies rendered from September 18,
2020, to September 24, 2020.

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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS
suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the enteral nutrition supplies rendered from September 18,
2020, to September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the advance care planning services coded 99497 provided on
September 2, 2020.

You asked the Plan to pay for the advance care planning services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the
documentation.

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 99497 is advance care planning including the explanation
and discussion of advance directives such as standard forms (with completion of such forms, when performed),
by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient,
family member(s), and/or surrogate.

We find that CPT code 99497 is not supported in the medical record. Specifically, the documentation submitted
did not include the documentation of a discussion between the provider and the patient, along with family
member(s), or surrogate(s), regarding eventual end-of-life decisions and preferences; therefore, the billed
service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the
advance care planning services have not been met. Therefore, we decided that the Plan does not have to pay for
the advance care planning services coded 99497 provided on September 2, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).

You asked the Plan to pre-approve a Vertiflex procedure. You say that the requested treatment is considered safe and effective. The Plan denied your request. The Plan says the procedure is 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 a Vertiflex procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a herniated disc at vertebrae L4-L5 which has not been addressed. The request for insertion of an interspinous spacer is not supported by clinical practice guidelines. 

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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex procedure (22869, 22870).