Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for occupational therapy provided by an occupational therapy assistant on December 23, 2020.

You asked the Plan to pay for occupational therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service provided.

The Plan must follow Medicare rules. Medicare rules say that the services of an OTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy provided by an occupational therapy assistant on December 23, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.

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 that the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

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 medically necessary. Our physician reviewer found the enrollee is diagnosed with stage IV non-small cell lung cancer with biopsy-proven intraabdominal metastases. The CT is requested to evaluate treatment response to Keytruda. CT is a useful imaging tool when there is a suspicion of tumor in the abdomen or pelvis and also for follow-up of patients with known oncologic pathology. Follow-up of oncologic disease should, in most cases, be performed using CT. The services are therefore reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.

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 information to 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 28, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. 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 a covered benefit.

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 office visit provided on December 28, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sacral spine facet joint injections.
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that facet injections are covered when specific criteria are met. 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 Our physician reviewer found the records do not show that the enrollee had a consistent positive response of at least 80 percent pain relief after the first diagnostic facet joint injection. The criteria for coverage of further injections are not met and 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 sacral spine facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for standard eye lenses and frames (V2020, V2103, V2750) provided on April 16, 2021.

You asked the Plan to pay for standard eye lenses and frames. You say that you feel the denial is incorrect. The Plan denied your request. The Plan says your vision benefits were processed and paid on October 19, 2020, exhausting the two-year benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers 1 pair of lenses and frames once every 2 years. 

The services you asked the Plan to pay for are considered routine vision services or eyewear. The record shows that the Plan covered lenses and frames for you on October 19, 2020. This means that you have exhausted the Plan's benefit for lenses and frames and were not eligible for another pair on April 16, 2021. Therefore, we decided that the Plan does not have to pay for standard eye lenses and frames (V2020, V2103, V2750) provided on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT
code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has suffered from spinal stenosis for
three (3) years and has greatly impacted their quality of life. The Plan denied your request. The Plan says the
services are considered experimental and 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 the surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on March 21, 2021.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is only covered for certain indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Guardant360 testing. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee was diagnosed with stage IV metastatic lung disease to the lymph nodes and bones. A lymph node biopsy was completed March 16, 2021, consistent with metastatic non-small cell lung cancer. The plan was to start single agent chemotherapy, Pembrolizumab. Solid tumor tissue results were pending, and the enrollee was anticipated to start treatment early in April. There was no further documentation of treatment in the record or claims data available and appears the enrollee decided on hospice care. LCA criteria are not met as there is no documentation that tissue-based, comprehensive genomic profiling (CGP) is infeasible (e.g., quantity not sufficient for tissue-based CGP or invasive biopsy is medically contraindicated) or specifically in Non-Small cell Lung Carcinoma (NSLC) Tissue-based CGP has shown no actionable mutations. 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 Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on March 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an implantation of a wireless pulmonary artery pressure sensor (93264) provided on March 4, 2021, by an out-of-network provider.

You asked the Plan to pay for an implantation of a wireless pulmonary artery pressure sensor. You say that the requested service was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an implantation of a wireless pulmonary artery pressure sensor (93264) provided on March 4, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the second hospital inpatient admission provided from April 18, 2020, to April 21, 2020.
You asked the Plan to pay for the second hospital inpatient admission. You say that you would like these services to be reconsidered for coverage. The Plan denied your request. The Plan says that the unrelated inpatient hospital admission was not medically necessary.
The Plan follows Medicare rules. Medicare rules say that readmissions are denied if the readmission was medically unnecessary; and/or If the readmission resulted from a premature discharge from the same hospital. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the second hospital inpatient admission. Our reviewer says that the readmission was medically necessary. Our physician reviewer found the readmission did
not result from a premature discharge from the same hospital. At discharge on April 16, 2020 the enrollee was hemodynamically stable. Our reviewer found that the enrollee's Lactulose dose was appropriately decreased as he had evidence of acute kidney injury which improved with intravenous fluids. Our physician reviewer also found that the enrollee presented on April 18, 2020 as a consequence of poor oral intake. The enrollee had not been prematurely discharged on April 16, 2020. 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 second hospital inpatient admission have been met. Therefore, we decided that the Plan has to pay for the second hospital inpatient admission provided from April 18, 2020, to April 21, 2020.
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 information to 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 LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 LTACH services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided by a physical therapy assistant on
September 24, 2020.

You asked the Plan to pay for physical therapy. You say that the Plan is required to pay non-contracted providers at the preferred provider rate if the service is not available from a preferred provider. You say that many services were not available on an outpatient basis due to the pandemic and the claim should be processed for payment at the in-network benefit. The Plan denied your request. The Plan says the billed code is not appropriate for the service provided.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy provided by a physical therapy assistant on September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that 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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
fracture of humerus and ulna after a fall. Medical conditions are stable. There are no complex nursing or
rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. You do 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 you
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete lower denture (D5120) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the denture. You say that your current dentures do not fit properly and need to be replaced. The Plan denied your request. The Plan says out-of-network dental care is not covered. The provider in question is not part of the Plan's dental network.
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. The Plan only covers dental services when they are received from an in-network provider and are medically reasonable and necessary. We looked at the file and Medicare rules. This provider is not in the dental Plan's network. Based on this information, we decided that the Plan's rules for coverage of the denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete lower denture (D5120) to be provided by an out-of-network provider.
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 is stable and can safely be transferred to LTACH level of care for continuation of care of complex respiratory and medical needs. The Plan denied your request. The Plan says enrollee is receiving appropriate in-patient acute care; does not require transfer to LTACH.
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 does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care facility. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 13, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing/panels.

The Plan must follow Medicare rules. 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 pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records.

Our physician reviewer found this form of testing is not medically reasonable and necessary as it has not sufficiently proven to lead to significant changes in treatment or cardiovascular outcomes to support its general use.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on November 13, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided on August 21, 2020, by a PT assistant (PTA).

You asked the Plan to pay for the PTA services. You say that this should be paid and is billed correctly. The Plan denied your request. The Plan says there is a more appropriate code to be used for these services.

The Plan must follow Medicare rules. Medicare rules say that PTA services cannot be billed incident to the services of a physician or NPP, only a therapist.

We looked at the file and Medicare rules. We find that these services were billed by an NPP. Services of a PTA are not payable to a provider that is not a therapist. Based on this information, we decided that Medicare rules for coverage of the PTA services have not been met. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided on August 21, 2020, by a PT assistant (PTA).