Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block (64454).

You asked the Plan to pre-approve a genicular nerve block (64454). You say that the requested genicular nerve block (64454) is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve block (64454) 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 genicular nerve block (64454). Our reviewer says that the requested genicular nerve block (64454) is not medically necessary. Our physician reviewer found genicular nerve blocks are considered investigational and not medically necessary for the treatment of chronic knee pain, including, but not limited to any of the following: degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment following knee replacement; or as a treatment for individuals who are not candidates for knee replacement surgery. 

The clinical value and effectiveness of a genicular nerve block in the setting of chronic knee pain have not been demonstrated in the peer-reviewed literature.

The review has determined that the requested genicular nerve block of the right knee is not medically reasonable or 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 genicular nerve block (64454) have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64454).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that the additional PT is medically necessary. The Plan denied your request. The Plan says the additional PT is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 ten (10) additional PT visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee has achieved maximum level of anticipated function. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the enrollee's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point to maintain the enrollee's improvement. There is no documentation that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist or under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 SNF services are 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 you have no identifiable skilled nursing service needs nor skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 SNF care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a specialist office visit. You say that you would like to use this provider because he has been your doctor in the past. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard, colon cancer screening (81528).
You asked the Plan to pre-approve the Cologuard screening. You say that you are appealing this decision per your doctor's recommendation. You doctor said a colonoscopy could have a damaging effect for you so please reconsider covering the cost of this kit. The Plan denied your request. The Plan says the enrollee does not meet
all of the criteria as he exceeds the age limit and is not at average risk due to previous history and family history of colon cancer.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Cologuard screening have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cologuard, colon cancer screening (81528).
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 coronary artery bypass grafting, aortic valve replacement and placement of a pacemaker. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient admission for the approved right total shoulder arthroplasty (23472).
You asked the Plan to pre-approve inpatient admission for the approved right total shoulder arthroplasty (23472).
You say that the requested inpatient stay for the approved right total shoulder arthroplasty (23472) is medically necessary. The Plan denied your request. The Plan says the requested inpatient stay for the approved right total shoulder arthroplasty (23472) 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 inpatient admission for the approved right total shoulder arthroplasty (23472). Our reviewer says that the requested inpatient stay for the approved right total shoulder arthroplasty (23472) is not medically necessary. Our physician reviewer found the enrollee was being treated for right shoulder arthropathies; pain in right shoulder; rotator cuff tear or rupture of right shoulder. The requested total shoulder arthroplasty is documented to have been supported. However, detailed documentation is not evident regarding a significant past and/or current medical history that would clearly place this enrollee at a significantly increased risk for peri-surgical complications requiring an inpatient stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission for the approved right total shoulder arthroplasty (23472) have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient admission for the approved right total shoulder arthroplasty (23472).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81162) provided July 14, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the service cannot be paid as billed under Medicare rules.

The Plan must follow Medicare rules. Medicare rules say that a panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

We looked at the file and Medicare rules. Multiple CPT codes were submitted for this panel. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81162) provided July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.

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 step therapy requirement is not met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 enrollee has joint pain and stiffness related to rheumatoid arthritis. She has not tried and failed the Plan's required drugs of Remicade, Inflectra, or Simponi Aria. The records do not show that the required drugs would be contraindicated or less effective; therefore, Rituxan is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99214) to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit (99214) to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lunbar-sacral orthosis (LSO) rendered on January 27, 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 the services are not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

We looked at the file and Medicare rules. The file shows that the services were billed to the office setting, which is not inside the home. Therefore, we decided that the Plan does not have to pay for the lunbar-sacral orthosis (LSO) rendered on January 27, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for subsequent hospital care (99232) provided on November 30, 2020, through December 2, 2020.
You asked the Plan to pay for the subsequent hospital care. You say that you would like reconsideration because these services were rendered by different providers on the same date of service. The Plan denied your request. The Plan says that this claim denied as a duplicate and a previous claim was processed and paid.
The Plan must follow Medicare rules. Medicare rules say that physicians in the same group practice but who are in different specialties may bill and be paid without regard to their membership in the same group. We find that CPT code 99232 is supported in the medical record. Specifically, the record indicates that this claim is not a duplicate. The billing provider in this case has a different specialty than that of the physician on the claim which was previously paid. The record indicates that these physicians were involved in separate parts on the member's care on the billed dates of service. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care have been met. Therefore, we decided that the Plan has to pay for subsequent hospital care (99232) provided on November 30, 2020, through December 2, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99213, 99214) rendered by the out-of-network (OON) provider on May 7, 2020 and August 25, 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 office visits (99213, 99214) rendered by the out-of-network (OON) provider on May 7, 2020 and August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic inserts provided on February 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for orthotic inserts. You say that you called and made sure that these would be covered. The Plan denied your request. The Plan says these inserts could have been provided in-network. The Plan says that 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for orthotic inserts provided on February 23, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that criteria are met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess 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 use insulin with at least three daily injections. The most recent progress note shows an order for only two daily injections of Lantus insulin. Based on this information, we decided that Medicare rules for coverage of the CGM have not
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Neuro-Oncology Expanded Gene Panel with Rearrangement (CPT code 81455) provided to the enrollee on March 5, 2021.
You asked the Plan to pay for the laboratory testing. You say that the service was medically necessary. The Plan denied your request. The Plan says the service has not met the requirements of either Medicare
Administrative Contractor (MACs) technical assessment processes. The Plan states it is not Food and Drug Administration (FDA) Approved Companion diagnostic so does not meet the national requirements per national coverage determinations (NCD) 90.2.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. Many applications of the molecular pathology procedures are not covered services given lack of benefit category (e.g., preventive service or screening for a genetic abnormality in the absence of a suspicion of disease) and/or failure to the reasonable and necessary threshold for coverage (e.g., based on quality of clinical evidence and strength of recommendation or when the results would not reasonably be used in the management of a beneficiary). Therefore, we decided that the Plan does not have to pay for Neuro-Oncology Expanded Gene Panel with Rearrangement (CPT code 81455) provided to the enrollee on March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81455) provided March 19, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this procedure is not covered.

The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code
81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be
denied as not medically necessary.

We looked at the file and Medicare rules. The service at issue was billed using code 81455. This is not a
covered service. Based on this information, we decided that Medicare rules for coverage of the lab services
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided
March 19, 2021.