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

We decided that the Plan does not have to pre-approve BRCA 1 and BRCA 2 genetic testing.
You asked the Plan to pre-approve BRCA 1 and BRCA 2 genetic testing. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says you do not meet criteria for the
requested services.
The Plan must follow Medicare rules. Medicare rules say that BRCA 1 and BRCA 2 genetic testing is only
covered for certain indications.
We looked at the file and Medicare rules. Review of the file shows that you have no personal or family history
of ovarian, uterine, prostate, or pancreatic cancers. All genes in the requested multi-gene panel testing are not
relevant to your personal and family history. Based on this information, we decided that Medicare rules for
coverage of BRCA 1 and BRCA 2 genetic testing have not been met. Therefore, we decided that the Plan does
not have to pre-approve BRCA 1 and BRCA 2 genetic testing.
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 needs admission to LTACH. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for 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 appears to be failing weaning attempts and requires only short-term additional acute care services for additional weaning attempts which can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time as there would be limited advantage to transfer at this time. 

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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on May 13, 2021.

You asked the Plan to waive the copayment for a CT scan. You say that you did not receive contrast like you
were supposed to and were never informed that you would owe such a high copayment and cannot afford the
charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being
charged the correct amount.

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 pay a $250
copayment for CT scans.

You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient diagnostic
tests and therapeutic services and supplies benefit category. 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 copayment
for a CT scan provided on May 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery.
You asked the Plan to pre-approve backup battery. You say that you need this due to irregularities and instability in your electrical power. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because a backup battery is not primarily medical in nature and is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a backup battery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continued skilled nursing facility (SNF) care.

You asked the Plan to pay for continued SNF care. The Plan denied your request. The Plan says this 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 pay for continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that as of August 20, 20201, the enrollee does not require any skilled nursing or rehab services on a daily basis. She is not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living (ADLs). The enrollee does not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee does not require any skilled services on an inpatient basis, at a SNF 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pay for continued skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on March 4, 2021, and March 5, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.
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 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes". We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not show that 30-74 minutes of critical care services were provided on the dates of service in question. 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 critical care services (99291) provided on March 4, 2021, and March 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376)
You asked the Plan to pre-approve the diagnostic service. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the requested 3D rendering is 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 the diagnostic service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Based on the clinical documentation, the patient does warrant imaging, however, there was no clear explanation as to why 3D rendering would be needed over standard images in this case. Therefore, this request for 3D rendering will be considered not medically necessary at this time. 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 diagnostic service have not been met. Therefore, we decided that the Plan does not have to pre-approve 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the occupational therapy evaluation provided on March 3, 2021.
You asked the Plan to waive the deductible for the occupational therapy evaluation. You say that you were advised by the providers office that you would only be responsible for the $15 copayment. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your combined in-network and out-of-network medical deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. for
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient Rehabilitation
Services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your
$300 deductible applies to outpatient therapy services. This is the amount you have to pay out-of-pocket before
we will pay our share for your covered medical services. Until you have paid the deductible amount, you must
pay the full cost for most of your covered services. This cost sharing is a contractual obligation that had not
been met at the time the occupational therapy evaluation was received on March 3, 2021. Therefore, we
decided that the Plan does not have to waive the deductible for the occupational therapy evaluation provided on
March 3, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the morphometric analysis, tumor immunohistochemistry (88360), and the microdissection (88381) provided on January 26, 2021.
You asked the Plan to pay for the laboratory services. You say that the referring provider requested biomarker testing. You also say that these services should be covered. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
The Plan also says it is the provider's responsibility to verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the morphometric analysis, tumor immunohistochemistry (88360), and the microdissection (88381) provided on January 26, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay from December 16, 2020, to January 14, 2021.
You asked the Plan to waive the copayment for a SNF stay. You say that you were in the facility until December 31, 2020, which would equal 16 days so you should not owe a copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 pay a $0 copayment for days 1-20, and a $150 copayment for days 21-100 for SNF care. The medical records show that you had a SNF stay from December 16, 2020, to January 14, 2021. You are not
being charged a copayment for days 1-20 (December 16, 2020, to January 4, 2021). You are responsible to pay a $150 copayment for days 21-29 (January 5, 2021, to January 13, 2021). However, you are only being asked to pay $1,200, which is less than the total copayment amount. You have been asked to pay $1,200 for a SNF stay. A SNF stay falls within the SNF care benefit category. 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 copayment for a SNF stay from December 16, 2020, to January 14, 2021.
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 you feel the enrollee meets Medicare criteria for acute inpatient rehabilitation and will benefit from acute inpatient rehabilitation that cannot be accomplished at a lower level of care. The Plan denied your request. The Plan says the IRF services at request do not meet the requirements for approval.
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. Our reviewer found that the enrollee 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. Our physician reviewer also found that 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve group 2 power wheelchair (motorized wheelchair used to assist people with restricted mobility), deep back rest and accessories (CPT code(s): E2361, E2615, K0822), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee lives in a very large SNF with many patients on their floor. You state the enrollee has a caregiver who cannot push manual wheelchair but can propel the power wheelchair using an attendant control. You state that caregivers in skilled nursing facilities have many patients to attend to; the enrollee would be stuck in their room until staff are available. The Plan denied your request. The Plan says the enrollee lives in a SNF with 24 hour a day care and staff that are able push a manual wheelchair. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the DME is being requested for use in a SNF or hospital. Therefore, we decided that the Plan does not have to pre-approve group 2 power wheelchair (motorized wheelchair used to assist people with restricted mobility), deep back rest and accessories (CPT code(s): E2361, E2615, K0822), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you need compression stockings. The Plan denied your request. The Plan says you do not suffer from ulcers, burns or surgical wounds therefore the compression stockings are not covered.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency ambulance services (A0427, A0425) provided on January 26, 2021.

You asked the Plan to waive the copayment for emergency ambulance services. You say that the services were necessary, and you had no control over the transportation. The Plan denied your request. The Plan says the copayment was applied correctly.

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 pay a $200 copayment for ambulance services. 

You have been asked to pay a $200 copayment for emergency ambulance services. The services at issue fall within the ambulance services benefit category. 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 copayment for emergency ambulance services (A0427, A0425) provided on January 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for intra-operative neurophysiological monitoring (95861,
95868, 95927, 95938) provided on January 7, 2021.

You asked the Plan to pay for intra-operative neurophysiological monitoring. You say that this should be
covered. The Plan denied your request. The Plan says this was billed with the incorrect place of service (POS)
code.

The Plan must follow Medicare rules. Medicare rules say that if the mobile unit is serving an entity for which
another POS code already exists, providers should use the POS code for that entity.

We looked at the file and Medicare rules. The services at issue were billed with Mobile Unit POS code 15, but
the records show that they were provided in service of an entity for which another POS code already exists.
Based on this information, we decided that Medicare rules for coverage of intra-operative neurophysiological
monitoring have not been met. Therefore, we decided that the Plan does not have to pay for intra-operative
neurophysiological monitoring (95861, 95868, 95927, 95938) provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network office visit. You say that you have been diagnosed with human papillomavirus (HPV) and want to go to this provider just in case you need to have surgery and you will be closer to your family. You state that this is the only provider you trust to be able to help you. The Plan denied your request. The Plan says there are in-network providers available who can supply the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625), for the enrollee.
You asked the Plan to pre-approve the service. You say that the enrollee received 50% relief for about one (1) month from the SI steroid injection performed on April 19, 2021. You state you are requesting the RFA to provide longer lasting relief of these nerves. The Plan denied your request. The Plan says research has not proven to be helpful and it is considered experimental or 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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found RFA of the SI joint remains experimental for back pain treatment. More research is needed to show safety and efficacy of the device. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (ie, fluoroscopy or computed tomography) (CPT code 64625), for the enrollee.