Persius/hicric huggingface dataset:
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 records provided support the need for IRF care.
The Plan denied your request. The Plan says the records show that the enrollee's rehabilitation needs are not
complex. The Plan says that the enrollee can safely receive the care needed in other settings.
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 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 repair of an ankle fracture after a fall. The enrollee's medical conditions are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy
program. The enrollee does require physical and occupational therapy but there is no documented need for an
intensive rehabilitation program. Medically necessary services can be provided in a different level of care.
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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial nursing facility care (CPT code 99306) and subsequent nursing facility care (CPT Code(s): 99307 and 99308) provided to the enrollee from May 26, 2019, through June 7, 2019, by an out-of-network provider.

You asked the Plan to pay for the medical services. You say that the claims should be paid. The Plan denied your request. The Plan says the claims were not filed timely within twelve (12) months of the date of service. The Plan states it is the providers responsibility to check the enrollee's benefits and eligibility prior to services being rendered.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the medical services was not filed until December 14, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for initial nursing facility care (CPT code 99306) and subsequent nursing facility care (CPT Code(s): 99307 and 99308) provided to the enrollee from May 26, 2019, through June 7, 2019, by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the home health aide or certified nurse assistant,
providing care in the home, per hour (S1922) provided on June 8, 2020.

You asked the Plan to reimburse you for the home health service. You say that you need to be reimbursed for
the blood draw that you received in your home. The Plan denied your request. The Plan says the provider in
this case does not participate with Medicare. The Plan also says that services rendered by a provider who does
not participate with Medicare are not covered.

The Plan must follow Medicare rules. Medicare rules say that a provider or supplier must be enrolled in the
Medicare program to receive payment.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the home health service have not been met. Therefore, we decided that the Plan does not have to
reimburse you for the home health aide or certified nurse assistant, providing care in the home, per hour
(S1922) provided on June 8, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation
and/or forceps removal) (D7140) received December 8, 2020, from an out-of-network provider.
You asked the Plan to pay for the extraction. You say that you had a dental emergency, and your network
provider was not able to provide timely service. The Plan denied your request. The Plan says there is no
coverage for services rendered by an out-of-network provider.
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 requested items or services are not
among those covered under this benefit. The Plan does not provide coverage for services when rendered by an
out-of-network provider. Therefore, we decided that the Plan does not have to pay for the extraction, erupted
tooth or exposed root (elevation and/or forceps removal) (D7140) received December 8, 2020, from an out-ofnetwork
provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug test 15-21 classes (CPT code G0482) provided to the enrollee on November 25, 2020, by an out-of-network provider.
You asked the Plan to pay for the drug test. You say that the laboratory testing ordered by the referring provider was deemed to be medically necessary. The Plan denied your request. The Plan says the request is from an out-of-network provider. The Plan states it has been pointed out to this provider on multiple occasions that preauthorization is required for the requested testing. The Plan states there is no preliminary drug test provided that showed an inconsistent result, and there is no documentation from the enrollee's doctor as to why 15-21 drug classes are needed to manage this enrollee's care.
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 drug test 15-21 classes (CPT code G0482) provided to the enrollee on November 25, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64494 provided on September 9, 2020.

You asked the Plan to pay for the injection 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 payable.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.

In this case, the MUE for CPT code 64494 is 1. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met.

Therefore, we decided that the Plan does not have to pay for the injection services coded 64494 provided on September 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular artery embolization.
You asked the Plan to pre-approve genicular artery embolization. You say that you wish to avoid surgical intervention due to complications brought by previous surgeries. The Plan denied your request. The Plan says there does not appear to be any clinical benefit for the requested procedure.
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 genicular artery embolization. Our reviewer says that genicular artery embolization is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a medical history that includes bilateral osteoarthritis and is requesting genicular artery embolization of the right knee to address longstanding history of pain. Despite conservative treatment options which included NSAIDs, steroid joint injections and HLA joint injections, the enrollee's pain continued to persist. The enrollee underwent magnetic resonance imaging (MRI) of the right knee on February 26, 2021, which showed severe tricompartmental osteoarthrosis, most advanced in the lateral and patellofemoral compartments. The findings are superimposed on a macerated and extruded lateral meniscus. There is small joint effusion and popliteal cyst with synovitis. Our physician reviewer found that
embolization is not indicated for osteoarthritis, but rather for treatment of hemorrhage or shrinkage of a mass. There is no clinical rationale for the requested genicular artery embolization. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular artery embolization.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve initiation of home health (HH) services, 4 skilled nursing visits, 12 physical therapy (PT) visits, and 10 occupational therapy (OT) visits.
You asked the Plan to pre-approve the requested HH services. You say that home health care is needed to assist with function and monitor her health condition. The Plan denied your request. The Plan says the treatment plan does not include specific measurable goals. As such, the services are not shown to be medically necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 requested HH services. Our reviewer says that the documentation does not support the medical necessity of the requested HH services. Our physician reviewer found the documentation does not support that the member requires skilled nursing services or skilled rehab services to provide treatment that is medically necessary. She has been medically stable with continued chronic pain and a minimal decrease in function that does not appear to warrant the amount of requested services. The member does not require skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the member's condition, perform a maintenance program to maintain the member's condition and/or prevent deterioration. The member has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The requested home health services are not 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 the requested HH services have not been met. Therefore, we decided that the Plan does not have to pre-approve initiation of home health (HH) services, 4 skilled nursing visits, 12 physical therapy (PT) visits, and 10 occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a
Sanexas device reported on September 8, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You
say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan
says the record does not support that the procedures were performed as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression
or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is
application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The
HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals).
The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection
(specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code
J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection,
thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100
mg.
We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record.
Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer
of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the
criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was
applied to any area for any amount of time. The record states that the Sanexas device was applied using
standard programs. This does not support constant direct patient contact, which is required to report CPT code
97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed.
The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy
at the same time; the criteria for reporting CPT code 97150 has not been met.
Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record
does not contain documentation of the dosage and type of drug administered in each injection, which is
required by Medicare for these services to be reimbursed.
Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections
and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to
pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on September 8,
2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the continued SNF care. You say that you have had issues with COVID and still need to be on oxygen. You say that you have a problem with your fistula being clogged for dialysis. You say that you now have a port installed in your chest while they figure out the next step. You say that you need more time to heal while the doctors work to find a solution. The Plan denied your request. The Plan says there are no daily skilled complex nursing or therapy needs which would need to be provided on a daily basis in an inpatient only setting.

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 the continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee appears to be at his baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided 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 the continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 8, 2020.
You asked the Plan to pay for the cardiovascular risk assessment panel. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided 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 above, are not covered. Cardiovascular risk assessment panels are only covered for certain indications. Review of the file shows that the plan uses Local Coverage Determination (LCD) L36523 to support their denial. However, LCD L36523 is not valid for the provider's billing state of Florida. Therefore, we are unable to use LCD L36523 to substantiate our decision. While cardiovascular risk assessment panels are covered for certain indications, the file does not support that the enrollee met criteria for these services. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on December 8, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy services coded 29823 provided on
September 29, 2020.
You asked the Plan to pay for the arthroscopy 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 29823 is arthroscopy, shoulder, surgical; debridement,
extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid
articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator
cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).
We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report did not
include sufficient documentation to meet the guidelines of a surgical shoulder arthroscopy, with extensive
debridement, including 3 or more discrete structures (humeral bone, humeral articular cartilage, glenoid bone,
glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the
rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]); therefore this code cannot be
verified. Based on this information, we decided that Medicare rules for coverage of the arthroscopy services
have not been met. Therefore, we decided that the Plan does not have to pay for the arthroscopy services coded
29823 provided on September 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on January 21, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 continuous glucose monitor (CGM) supplies rendered on January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio screening panel provided on November 15, 2020.
You asked the Plan to pay for the services provided. You say that the services were rendered in good faith. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. We looked at the file and the rules. The records provided do not indicate the results of the testing would be used to determine a specific diagnosis or treatment strategy. The testing was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardio screening panel provided on November 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services provided from January 18, 2021, to March 10, 2021.
You asked the Plan to pay for the physical therapy provided by a chiropractor. You say that the traction table gives you a lot of relief from pain. The Plan denied your request. The Plan says these services provided by a chiropractor are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the physical therapy services provided from January 18, 2021, to March 10, 2021.