Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the 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 surgical repair of hip fracture and leg fracture and for non-surgical management of facial fractures and rib fractures after a motor vehicle collision. Medical problems 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. 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. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the fluoroscopic guidance rendered on March 2, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says procedure code 77001 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 77001 (fluoroscopic guidance) and 70498 (computed
tomography angiography of the neck). Code 77001 is a column II code with a modifier indicator of 1 when
billed with column I code 70498.
Code 77001 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided
that the Plan does not have to pay for the fluoroscopic guidance rendered on March 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from February 19, 2021, through February 21, 2021.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says prior authorization was not obtained.

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 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 inpatient admission provided from February 19, 2021, through February 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

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 Botox is covered for specific indications only. 

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 not medically necessary. Our physician reviewer found the records show that you have a mild scar on your forehead for which you have received past treatments of Botox. The scar has been treated with Botox and other means and is more than five years old and not causing serious symptoms. Treatment with Botox would be considered cosmetic in nature and not covered by Medicare. The services are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 2, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic met hods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not 
include definitive laboratory results for 22 or more drug classes to support the criteria for this code. Based on 
this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, 
we decided that the Plan does not have to pay for the drug testing coded G0483 provided on March 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the CPAP supplies provided on January 11, 2021 
by an out-of-network provider. 
 
You asked the Plan to reimburse you for the CPAP supplies. You say that you were not aware you needed to 
use an in-network supplier. The Plan denied your request. The Plan says you ordered from an out-of-network 
supplier without authorization. 
 
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 at issue in this appeal. The Plan did not pre-approve the items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the 
Plan does not have to reimburse you for the CPAP supplies provided on January 11, 2021 by an out-of-network 
provider.
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 weakness and chronic
inflammatory demyelinating neuropathy. Medical problems 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. While the documentation does support a need for
physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary
rehabilitation program.

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 joystick mount (K0108), egg switches (K0108), Calf pads (K0108), and positioning wedges (K0108) for a power wheelchair.
You asked the Plan to pre-approve the wheelchair accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that all items needed for the proper functioning of the approved cushions are included in the allowances of E2624; K0108 cannot be use for components of the wheelchair seat cushions. Medicare rules also state that a Column II code is included in the allowance for the corresponding Column I code when provided at the same time. We looked at the file and Medicare rules. Seat wedges are not separately payable and are included in the allowance for the seat cushion. The egg switches and joystick mounting are included in the already approved E2377 expandable controller. The base code K0862 for the wheelchair includes the calf rest pads. This item is not separately payable under an unbundled code. Based on this information, we decided that Medicare rules for coverage of the wheelchair accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a joystick mount (K0108), egg switches (K0108), Calf pads (K0108), and positioning wedges (K0108) for a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Feraheme Drugs (Q0138).
You asked the Plan to pre-approve Feraheme. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Feraheme. Our reviewer says that the drug is not medically necessary. Our physician reviewer found there is no documentation of iron deficiency anemia, chronic kidney disease, heart failure or intolerance to oral iron therapy. There is no specific clinical rationale for the requested Feraheme therapy and the requested use of Feraheme is not FDA-approved for your diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Feraheme have not been met. Specifically, the requested drug is not FDA approved or supported by medical compendia for your diagnosis. Therefore, we decided that the Plan does not have to pre-approve Feraheme Drugs (Q0138).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.

You asked the Plan to pre-approve the inpatient hospital admission. You say that your health was in enough serious danger to be transported to the emergency department. You say that your primary care physician deemed it medically necessary to admit you. The Plan denied your request. The Plan says an inpatient admission is not medically necessary.

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 pre-approve the inpatient hospital admission. Our reviewer says that the documentation does not support that the criteria for coverage of an inpatient admission are met in this case. Our physician reviewer found the enrollee has a medical history of advanced dementia, hypertension, and hyperlipidemia. The enrollee was sent from the nursing home on July 29, 2021, for apparently reporting chest pain. The enrollee was in the emergency room the day prior, after having an unresponsive episode and received 30 seconds of cardiopulmonary resuscitation (CPR). The enrollee was found to have an elevated potassium and elevated troponin. After extensive discussion with the primary care physician and the enrollee's wife, the emergency room doctor discharged the enrollee back to the nursing home to pursue comfort care for the enrollee due to his advanced dementia. They did not want any interventions or aggressive care. The enrollee was sent back the next day for reported chest pain. In the emergency department he was pleasantly demented and could not give any history. The enrollee denied chest pain or any other symptoms. The enrollee's troponin was mildly elevated, and an electrocardiogram (EKG) was non-ischemic. The enrollee's family chose to pursue hospice care. The enrollee did not have hemodynamic instability. The enrollee did not have aortic dissection. The enrollee did not have myocardial infarction. The enrollee was discharged to the skilled nursing facility on July 30, 2021. The record did not show that, at the time of the request for an inpatient admission, the requesting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation 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 the inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional 15-minute increments of moderate sedation 
services provided on March 19, 2021, billed with code 99153. 
 
You asked the Plan to pay for the additional moderate sedation time. You say that the denial is incorrect as the 
POS code is appropriate since the enrollee was a hospital outpatient. The Plan denied your request. The Plan 
says this code is not payable in the outpatient hospital setting. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is 
not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital 
outpatient departments. 
These services were provided to a hospital outpatient. Payment cannot be made to the physician for this service 
when provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the 
additional 15-minute increments of moderate sedation services provided on March 19, 2021, billed with code 
99153.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the spine x-ray interpretation provided on March 26, 2021.
You asked the Plan to pay for the spine x-ray interpretation (72070). You say that the Plan should pay this claim. The Plan denied your request. The Plan says procedure code 72072 was billed on a separate claim for the same day so code 72070 is considered bundled.
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, we have confirmed that code 72070 has a bundled relationship with code 72072 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the spine x-ray interpretation (72070) provided on March 26, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing (80307, G0482) rendered by the out-of-network (OON) provider on November 19, 2020.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 drug testing (80307, G0482) rendered by the out-of-network (OON) provider on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.

You asked the Plan to pre-approve a CGM and supplies. You say that you need this because you are diabetic and suffering from a brain injury. The Plan denied your request. The Plan says that you are administering insulin only twice per day.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81479 provided on February 16, 2021.

You asked the Plan to pay for the laboratory services. 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 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 CPT code 81479 is not supported in the medical record. Specifically, diagnostic laboratory tests must be ordered by the physician who is treating the enrollee, that is the physician who furnishes a consultation or treats an enrollee for a specific medical problem and who uses the results in the management of the enrollee's specific medical problem. Review of the file does not support that the services were ordered by the physician who is treating the enrollee.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81479 provided on February 16, 2021.
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 you would benefit from the inpatient rehabilitation level of care. The Plan denied your request. The Plan says that you would be safely and equally well served with skilled therapy services at an alternative level of care.
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 surgical repair of a hip fracture after a fall. Your medical problems 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. 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. 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 your 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 service