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

We decided that the Plan has to pay forthe skilled nursing facility (SNF) care services provided on June 30, 2019 and July 1, 2019.You asked the Plan to pay forthe SNF care services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services provided are custodial care services and are not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan is denying payment for dates of service June 30, 2019 and July 1, 2019 as services provided were custodial care services, which are not covered by Medicare or the Plan. However, the Plan did not provide any medical records for the June 30, 2019 and July 1, 2019 dates of service to confirm that the services the enrollee received were custodial care services. We are unable to make a determination without the records for the dates of service under review to confirm if Medicare criteria had not been met. We find that the Plan has not substantiated their reasoning for denial based on Medicare criteria.Therefore, we decided that the Plan has to pay forthe skilled nursing facility (SNF) care services provided on June 30, 2019 and July 1, 2019.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 informationto 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says services can be safely done at a lower level of care such as outpatient or home care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 documentation does not support that this enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an acute inpatient hospital stay, with an interdisciplinary approach. Treatment by multiple therapies is required. There is no reasonable expectation that the enrollee would be able to fully participate in and benefit from an intensive rehab 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansayscare can be provided in the current inpatient hospital.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 is currently undergoing treatment at an ACH for heart failure and severe aortic stenosis. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.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 Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora comprehensive metabolic panel (CPT 80053) provided to the enrollee on January 15, 2019.You asked the Plan to pay for the panel. You say that this should be paid for.The Plan denied your request. The Plan says upon review of the documentation submitted, the Plan is unable to verify the ordering physician's intent to request the individual laboratory tests.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 80053 is "Organ or Disease Oriented Panels."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 panel. Our reviewer says that the panel at issue in this case was not coded correctly. Our coding reviewer found the medical records provided do not include documentation confirming that the treating physician intended for the clinical diagnostic test to be performed. The Lab Order was not signed by the ordering physician.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 panel have not been met.Therefore, we decided that the Plan does not have to pay fora comprehensive metabolic panel (CPT 80053) provided to the enrollee on January 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous stabilization device
(Vertiflex procedure).
You asked the Plan to pre-approve Vertiflex procedure. You say that this procedure is medically necessary and
is recommended for Medicare coverage. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because medical studies have not proven that Vertiflex is helpful for
treatment of the enrollee's condition.
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 Vertiflex procedure. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this device remains experimental, more research is needed.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Vertiflex procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve insertion of an interspinous stabilization device (Vertiflex procedure).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nucynta.
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 self-administered drugs are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nucynta.
Benefits for these services 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure device.
You asked the Plan to pre-approve the requested device. You say that the enrollee needs to control her ups and downs in a daily journal. The Plan denied your request. The Plan says the device is only covered for home dialysis.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (RFA).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee
osteoarthritis. She has had diagnostic genicular nerve blocks that provided 70 to 100 percent pain relief. The
requested RFA of the genicular nerves is considered experimental/investigational in nature and is the subject of
ongoing clinical trials. The services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve genicular radiofrequency ablation (RFA).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs are custodial in nature.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).You asked the Plan to pre-approve a wireless capsule endoscopy. You say that this is medically necessary.The Plan denied your request. The Plan says the records do not show the enrollee has bleeding that has not been treated.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 wireless capsule endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found gastrointestinal bleeding was not documented in the submitted medical records. Were gastrointestinal bleeding present, sufficient pathology was found by esophagogastroduodenoscopy and colonoscopy for source. Evoking a likelihood of small bowel arteriovenous malformations as the basis for performing a capsule endoscopy is not supported by available records, nor is the medical necessity demonstrated for the wireless capsule endoscopy study.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 wireless capsule endoscopy have not been met.Therefore, we decided that the Plan does not have to pre-approve a wireless capsule endoscopy (91110).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram (CPT 93010) services provided to the enrollee on January 10, 2020.You asked the Plan to pay for the electrocardiogram. You say that this should be paid for.The Plan denied your request. The Plan says an appropriate modifier to represent the services as separate and distinct was not used.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 93010 is "Electrocardiogram, routine ECG with at least 12 leads."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 electrocardiogram. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found procedure 12004 -Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm was performed on the same date of service by the same physician and has a bundled relationship with CPT 93010. A modifier is allowed to unbundle these services providing the medical records support these procedures being separate and distinct from one another. The medical documentation does support these procedures as separate and distinct, however, a modifier to represent the services as separate and distinct was not appended to CPT 93010 when billed to the health plan, therefore 93010 is not eligible for separate reimbursement.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 electrocardiogram have not been met.Therefore, we decided that the Plan does not have to pay for electrocardiogram (CPT 93010) services provided to the enrollee on January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (00731) provided on October 6, 2019.You asked the Plan to pay for the anesthesia services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted upon Appeal Review does not indicate when the additional information was created, who created it and who performed the services. The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Specifically, the amended record does not comply with Medicare's medical record correction or addition protocols.Therefore, we decided that the Plan does not have to pay for anesthesia services (00731) provided on October 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe office visits, the Part B medications, the outpatient hospital observation, the biopsy, and the laboratory services provided from February 4, 2019 to December 20, 2019. You asked the Plan to waive the cost share forthe office visits, the Part B medications, the outpatient hospital observation, the biopsy, and the laboratory services. You say that you were told this coverage would take care of the difference from what Medicare paid. The Plan denied your request. The Plan says the copayments for the office visits have been reprocessed to reflect the correct copaymentamounts. You have been charged the correct cost sharing amount for the remaining services.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 paya $10 copayment for in-network primary care physician (PCP) services,20% coinsurancefor chemotherapy drugs and all other in-network drugs covered under Medicare Part B, a $45 copaymentfor in-network outpatient hospital observation services, a $250 copayment for in-network outpatient hospital surgery, and a $20 copayment for in-network laboratory services. You have been asked to pay a $10 copayment for each of the office visitsfrom April 2, 2019 to December 20, 2019.($10 x 10 visits = $100). The office visits fall within the "Physician/Practitioner services, including doctor's office visits" benefit category.You have been asked to pay a total of $7.92 which is 20% of the allowed amounts for the Part B medications from April 23, 2019 to December 20, 2019. The total allowed amount is $39.60. ($39.60 x 20% = $7.92). The Part B medications fall within the "Part B prescription drugs" benefit category.You have been asked to paya $45 copayment for the outpatient hospital observation on February 4, 2019.The outpatient hospital observation falls within the "Outpatient hospital services" benefit category.You have been asked to pay a $250 copayment for the biopsy on October 2, 2019. The biopsy falls within the "Outpatient hospital services" benefit category.You have been asked to paya $20 copaymentfor each of the laboratory services on July 17, 2019 and July 29, 2019. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.You have been asked to pay a total amount of $442.92 for the services from February 4, 2019 to December 20, 2019. 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 cost share forthe office visits, the Part B medications, theoutpatient hospital observation, thebiopsy, and the laboratory services provided fromFebruary 4, 2019 to December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says care can be safely received in a lower level of care, such as skilled nursing
facility.
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 you are able to receive services at your current health care setting and a lower level
of care and does not need to go to a LTACH to receive any services that are unavailable in her current setting.
Your needs can be currently managed in your present setting and you do not need the requested LTACH
services for the diagnosis and your condition and to be able to be furnished safely and effectively only on an
inpatient basis in an LTACH.
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 admission to a long term acute care hospital (LTACH).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you are currently in a SNF and have blood clots in your stomach, a stent in your heart, and fall a lot. You say that your previous doctor told you that you were not able to care for yourself and need to go to rehab. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage and does not require any daily skilled nursing services or daily skilled therapy services on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee had stable vital signs. The enrollee received physical therapy and occupational therapy. The enrollee was at a modified independent level with bed motility and transfers. The enrollee was at a stand-by assist level with gait up to 150 feet with a rolling walker. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.