Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician certification visit for home health services (G0180) provided on March 28, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a physician certification visit. You say that you should be covered under the nursing home authorization and the services are considered medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a physician certification visit for home health services (G0180)
provided on March 28, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Retacrit to be included in dialysis treatments
for the enrollee.
You asked the Plan to provide coverage for Retacrit. You say that this drug should be covered by the Plan. The
Plan denied your request. The Plan says this drug is not being requested appropriately. Maximus overturned the
Plans decision stating the Plan did not provide a clear reason for the denial. The Plan requested a reopen and
stated that payment of Retacrit through the End-Stage Renal Disease Prospective Payment System has not been
denied by the Plan. Coverage of the drug will be through the enrollee's dialysis provider. The Plan also states
the chart notes indicate the enrollee previously received Aranesp through his nephrologist, and that dialysis was
increased to 4 hours per session as of March of 2021. The Plan states the denial of Retacrit requested by the
oncologist under Part B as a separate charge is therefore correct.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
request services correctly. Providers must both request and report services with the appropriate codes. In this
case the oncologist is asking for separate approval of a drug that is typically combined within the request for
the entire dialysis service. In addition, this request does not coincide with the requested drug and dosage
changes requested by the nephrologist. It would appear the request for Retacrit for separate approval was done
in error. Therefore, we decided that the Plan does not have to provide coverage for Retacrit to be included in
dialysis treatments for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nails (11721) and removal of skin growths (11056) provided on April 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for podiatry services. You say that you informed the front desk secretary to obtain prior authorization and there was a misconception prior to obtaining authorization. You also say that you would like a onetime courtesy to waive the authorization policy. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 debridement of nails (11721) and removal of skin growths (11056) provided on April 22, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zarxio (Q5101).
You asked the Plan to pre-approve Zarxio. You say that the requested drug is medically necessary for the enrollee. The Plan denied your request. The Plan says drugs dispensed by a pharmacy are not covered under Medicare Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Zarxio (Q5101).
Benefits for Zarxio may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from September 2, 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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from September 2, 2021, forward.
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 the enrollee is a fall risk. The Plan denied your request. The Plan says the enrollee does not need an intensive therapy program with multiple visits from a rehab doctor.

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 osteomyelitis and left below the knee amputation. His medical problems are stable. There are no complex nursing needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF 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 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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Envisia Genomic testing.
You asked the Plan to pre-approve the genomic testing. You say that you would like reconsideration because this testing is medically necessary. The Plan denied your request. The Plan says records do not show autoimmune disease, occupational, environmental, and medication have been eliminated as causes of the pulmonary fibrosis.
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 genomic testing. Our reviewer says that the documentation does not support that the requested genomic testing is medically necessary or reasonable to diagnose, treat or otherwise manage the enrollee's health. Our physician reviewer found 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 genomic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Envisia Genomic testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the TempusIX breast gene panel provided on December 28, 2020.

You asked the Plan to pay for the TempusIX breast gene panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The genetic testing panel provided includes multiple gene testing that exceeds what is needed to guide treatment plans. This means the testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the TempusIX breast gene panel provided on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for shoulder joint replacement (CPT code 23472), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient care is necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 23472 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found the review indicates that the enrollee is medically stable and has been
provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code
23472 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The procedure
is currently approved as an ambulatory procedure. There is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay. The does not record show the admitting
physician reasonably expects that the enrollee's necessary hospital care will span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the acute inpatient hospital care for shoulder joint replacement (CPT code
23472), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit for chiropractic care and treatment (99211, 98940) provided on March 10, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that the member has a chronic instability and needs treatment when she has flare-ups. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 for chiropractic care and treatment (99211, 98940) provided on March 10, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Sacroiliac joint (SI joint) fusion (27279).
You asked the Plan to pre-approve SI joint fusion. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is 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 SI joint fusion. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not show imaging with severe SI joint pathology and it is unclear if the SI joint is the pain generator in this case of degenerative back pain. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint fusion have not been met. Therefore, we decided that the Plan does not have to pre-approve the Sacroiliac joint (SI joint) fusion (27279).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the left total hip arthroplasty (CPT code 27130), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient care is necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27130 is not listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee is scheduled for a total hip arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. The elements of the coverage rule 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for the left total hip arthroplasty (CPT code 27130), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the observation care discharge services (99217) provided on December 31, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable.
The Plan must follow Medicare rules. Medicare rules say that payment for an initial observation care code is for all the care rendered by the admitting physician on the date the patient was admitted to observation. We looked at the file and Medicare rules. In this case, the enrollee was admitted for observation and discharged on the same date of service. Initial observation care, represented by CPT code 99220, has been billed and paid for this date of service. It is inappropriate to bill a second observation care code when the enrollee is discharged on the same date as admission. 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 the observation care discharge services (99217) provided on December 31, 2020]
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 enrollee needs physical and occupational therapy. The Plan denied your request. The Plan says under Medicare, the request 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical management of a subdural hematoma. Medical problems are stable. There
are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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 inpatient rehabilitation facility (IRF) admission and services.