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

We decided that the Plan does not have to pay for the infectious disease testing provided on January 16, 2021.
You asked the Plan to pay for the infectious disease testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 in the Medicare rules section, are not covered. The infectious disease testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the infectious disease testing provided on January 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paravertebral blocks with guidance provided on January 15, 2021.

You asked the Plan to pay for the paravertebral blocks with guidance (64462). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the services were not billed in accordance with Medicare national Correct Coding Initiative Policy.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 64462 is 1 The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the paravertebral blocks with guidance have not been met. Therefore, we decided that the Plan does not have to pay for the paravertebral blocks with guidance provided on January 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.

You asked the Plan to pre-approve the physical therapy. The Plan denied your request. The Plan says the service is available within the primary network and member's condition is not an emergency.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided outside of the Plan's service area on March 24, 2021.

You asked the Plan to pay for chiropractic services. You say that you were told emergency situations were covered under your policy. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered when performed by a chiropractor or the provider is out-of-network with the Plan and authorization was not obtained.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

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 chiropractic services. Our reviewer says that these services do not meet the Medicare criteria for coverage of urgent out-of-are care. Our physician reviewer found it is not known whether you could have foreseen requiring these services prior to leaving the Plan's service area. The manual manipulation service was medically necessary. However, it would have been medically reasonable to delay this care until you returned to the Plan's service area. The records submitted do not include documentation of manual manipulation of the spine to correct subluxation.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Furthermore, the office visit and X-Ray provided are not covered by Medicare or the Plan when performed by a chiropractor. Therefore, we decided that the Plan does not have to pay for chiropractic services provided outside of the Plan's service area on March 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on January 21, 2021

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 the services provided by an out-of-network provider on January 21, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of basivertebral nerves at 3 levels.

You asked the Plan to pre-approve the RFA services. You say that the enrollee has failed conservative treatments without relief. The Plan denied your request. The Plan says medical studies have not shown that the requested procedure works better than others.

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 RFA services. Our reviewer says that the radiofrequency ablation services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. She is status post the minimally invasive lumbar decompression (MILD) procedure at L3-L4 and foraminotomy. She has tried physical therapy. Her magnetic resonance imaging shows multi-level degenerative disc disease with modic changes. The requested RFA services are considered an experimental/investigational.

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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of basivertebral nerves at 3 levels.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne CDx testing rendered on July 8, 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 the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee has a diagnosis of high grade serous carcinoma. The records do not show that she meets the criteria for testing for hereditary breast or ovarian cancer and a risk factor for germline (inherited) breast or ovarian cancer. The testing was 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 pay for the FoundationOne CDx testing rendered on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a total shoulder arthroplasty (23472).

You asked the Plan to pre-approve an inpatient admission for a total shoulder arthroplasty. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can be treated as an outpatient.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.

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 an inpatient admission for a total shoulder arthroplasty. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found there is no record of the patient being at a high risk of complication or prolonged recovery from this planned procedure. There is no indication that the patient will require hospital services that would likely cross 2 midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient admission for a total shoulder arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a total shoulder arthroplasty (23472).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on November 9, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 the services provided by an out-of-network provider on November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 1, 2020, and December 2, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that considering the enrollee's advanced age, medical history, traumatic injuries, and clinical preservation, the enrollee required emergent evaluation and continued treatment for the traumatic injuries and post-stabilization care. The Plan denied your request.
The Plan says there was no expectation of a 2 midnight length of stay and no indication of an inpatient order. The Plan also says that the enrollee also stayed only 1 night.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record show does not that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 1, 2020, and December 2, 2020.
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 documentation does not support that it is medically reasonable and necessary to provide skilled therapy services on a daily basis in a skilled nursing facility 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 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on April 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.

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 the services provided on April 2, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 30, 2021 to May 2, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that you were admitted to the hospital after arriving at the emergency department, and this care was medically necessary. The Plan denied your request. The Plan says your condition did not support the necessity for the inpatient care.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record indicates that the enrollee was admitted after presenting to the emergency department with exertional chest pain and shortness of breath on April 30, 2021 and was subsequently discharged on May 2, 2021. The record indicates that the enrollee has a known coronary artery disease and has received previous treatments. The record shows that the enrollee was determined to have a moderate risk for a cardiac event. Observation and further evaluation were required and received. The record does not document that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee could have been admitted for observation rather than as an inpatient. The elements of the coverage rule are not satisfied; the requested services are not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 30, 2021 to May 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the CPAP and accessories provided on December
29, 2020.
You asked the Plan to reimburse you for the CPAP and accessories. You say that the CPAP is medically
necessary. The Plan denied your request. The Plan says the supplier is not contracted with Medicare.
The Plan must follow Medicare rules. Medicare rules say that for equipment to be covered it must be purchased
from a Medicare certified supplier.
We looked at the file and Medicare rules. Medicare will only cover your Durable Medical Equipment (DME) if
your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards
to enroll and stay enrolled in Medicare. If your doctors or suppliers aren't enrolled, Medicare won't pay the
claims submitted by them. Based on this information, we decided that Medicare rules for coverage of the CPAP
and accessories have not been met. Therefore, we decided that the Plan does not have to reimburse you for the
CPAP and accessories provided on December 29, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the preparation of a tumor cavity (19294) and partial mastectomy (19301) provided on November 10, 2020.
You asked the Plan to pay for the surgery services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a registered nurse first assistant is not recognized for payment by CMS.
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 preparation of a tumor cavity (19294) and partial mastectomy (19301) provided on November 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that the enrollee would benefit from therapy to improve his conditions. The Plan denied your request. The Plan says that the enrollee could have the care he needs at home with help.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for
you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested
level of care 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 pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that, based on the documentation provided,
you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have
documented skilled therapy needs. You are ambulating household distances and tending to activities of daily
living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance
program or to prevent deterioration of your condition. At this point, your care needs are custodial.
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 continued SNF care.