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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled
nursing or therapy services on a daily basis. This beneficiary does 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forGuardant360 testing provided to the enrollee on October 20, 2020.You asked the Plan to pay for the testing. You say that this should be paid for.The Plandenied your request. The PlansaysMedicare requires use of CPT 81479 to report a Guardant360 molecular pathology genomic profiling for breast cancer.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay forGuardant360 testing provided to the enrollee on October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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
enrollee does not meet criteria for IRF admission. 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 total hip replacement for
osteoarthritis. 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, in 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.

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 skin substitute graft (CPT 15275) services provided to the enrollee on December 2, 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 the records do not support the services 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 CPT Code Manual definition of code 15275 is "application of skin substitute graft to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, for total wound surface area up to 100sq cm; for the first 25sq cm or less wound surface area." 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 the medical records provided does not include sufficient documentation to validate that an application of skin substitute graft to the face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits,
for total wound surface area up to 100sq cm; for the first 25sq cm or less wound surface area was the service performed on December 2, 2020, therefore, this service cannot be verified. There is no documentation of a fixation technique. 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 skin substitute graft (CPT 15275) services provided to the enrollee on December 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy services rendered on September 14, 2020.
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 procedure code 97530 is not supported.
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 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the records show that the services were performed in the home or hospice setting and there is a more appropriate code for these services.
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 occupational therapy services rendered on September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the external electrocardiographic recording, review and interpretation by a physician or other qualified health care professional (93224) provided on January 7, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that he must pay a $40 copayment for a specialty care physician visit. The enrollee has been asked to pay a $40 copayment for the specialty care physician visit provided by phone. This means that the enrollee has been asked to pay the correct amount based on his contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the external electrocardiographic recording, review and interpretation by a physician or other qualified health care professional (93224) provided on January 7, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvefacet joint injections.You asked the Plan to pre-approvefacet joint injections. You say that the services are necessary.The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that Facet Joint Interventions are considered medically reasonable and necessary 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 facet joint injections. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have radicular pain, rather he has complex regional pain syndrome (CRPS) which is spreading. The LCD has a utilization limit of 2 levels bilaterally.Two levels of diagnostic medial branch block (MBBs) are medically reasonable and 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 facet joint injections have been met.Therefore, we decided that the Plan has topre-approvefacet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy (D3320) for tooth #20.
You asked the Plan to pre-approve endodontic therapy. You say that this service is medically necessary. The Plan denied your request. The Plan says endodontic services are not covered by the supplemental dental benefit.
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. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy (D3320) for tooth #20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical non-invasive osteogenesis stimulator
You asked the Plan to pre-approve an electrical non-invasive osteogenesis stimulator. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage of this service have not been met.
The Plan must follow Medicare rules. Medicare rules say that a noninvasive stimulator device is covered only for nonunion of long bone fractures or failed fusion. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical osteogenic stimulator. Serial radiographs must include a minimum of 2 sets of radiographs, each including multiple views of the fracture site, separated by a minimum of 90 days. We looked at the file and Medicare rules. The submitted medical records do not include at least 2 sets of radiographs. Based on this information, we decided that Medicare rules for coverage of an electrical non-invasive osteogenesis stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an electrical non-invasive osteogenesis stimulator
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation (A0120).
You asked the Plan to pre-approve additional routine trips. You say that the additional transportation requested is necessary for upcoming doctor's appointments. The Plan denied your request. The Plan says you have exhausted the allowable benefit for this service, this calendar year.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 48 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a spinal orthosis (L0650), a knee orthosis (L1852), and a miscellaneous durable medical equipment accessory (A9900) provided on August 26, 2020.
You asked the Plan to pay for a spinal orthosis, a knee orthosis, and a miscellaneous durable medical equipment accessory. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says documentation does not sufficiently document the enrollee's medical condition to
support the medical necessity for the billed supply code, nor does documentation indicate that the provider discussed the need for the billed supply code.
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 a spinal orthosis, a knee orthosis, and a miscellaneous durable medical equipment accessory. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Medicare criteria have not been met for an L0650 lumbosacral orthosis. The documentation does not reveal an objective physical examination of the lumbar spine or a detailed neuromuscular system. There is no evidence on a physical exam that indicates the enrollee's pain is reduced by restricting trunk mobility. There is no evidence of a recent injury or surgery to the spine or related soft tissues that requires the orthosis to facilitate healing. There is no evidence on an objective physical exam of weak or deformed spinal muscles. The Medicare criteria have not been met for a L1852 knee orthosis. There is no evidence of a detailed properly performed neuromuscular examination or gait evaluation. There is no evidence of true instability on a physical exam. The "objective" does not indicate pathological laxity with objective measurements of any laxity of the knee. There is no evidence of a recent surgery or injury to the knee. The enrollee is noted ambulatory but there is no evidence the enrollee requires the requested knee brace. As the documentation does not support the requested L0650 and L1852 are medically necessary, the requested A9900 is also 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 a spinal orthosis, a knee orthosis, and a miscellaneous durable medical equipment accessory have not been met. Therefore, we decided that the Plan does not have to pay for a spinal orthosis (L0650), a knee orthosis (L1852), and a miscellaneous durable medical equipment accessory (A9900) provided on August 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the Enterectomy, resection of the small intestine (44120) provided on November 1, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service is not payable as the provider is ineligible for payment according to Medicare rules.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the Enterectomy, resection of the small intestine (44120) provided on November 1, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is diagnosed with spinal stenosis, lumbar region with neurogenic claudication. The Vertiflex device is experimental. 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
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 LTACH care is medically necessary. The
Plan denied your request. The Plan says rules for LTACH care 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 patient is currently undergoing treatment at an acute care hospital (ACH). The
enrollee's hospitalization was complicated by pneumonia, an abdominal wall abscess and renal failure. The
enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has been weaned from
the ventilator and is no longer receiving hemodialysis. 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 LTC 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 Plan
does not have to pre-approve LTACH services.
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 these services are medically necessary. The Plan
denied your request. The Plan says that records do not show that you need an intensive program with a team of
health care professionals and doctors that specialize in complex medical needs as well as rehab.
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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care. You were admitted for syncope, dehydration and a fall. Your 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral out-of-network for oxygen equipment.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are network providers available who provide this equipment.
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 a referral out-of-network for oxygen equipment.