Persius/hicric huggingface dataset:
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 the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted with shortness of breath due to exacerbation of chronic obstructive pulmonary disease. The record indicates that the enrollee has improved but still requires BiPAP. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for interim caries arresting medicament application (D1354)
provided on April 5, 2021.
You asked the Plan to pay for interim caries arresting medicament application. You say that the service should
be covered, and you want the Plan to pay. The Plan denied your request. The Plan says the service at issue is
not a covered 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 pay for interim
caries arresting medicament application (D1354) provided on April 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided May 20, 2020.
You asked the Plan to pay for the electronic shock unit. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the billed supply code cannot be verified.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery or a delivery ticket or relevant medical records which support medical necessity for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided May 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show any physical therapy.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has polymyalgia rheumatica, has failed back syndrome, severe degenerative changes and no sclerosis at the sacroiliac joint. The record does not indicate that the enrollee has tried and failed conservative medical management or physical therapy. The record does not support the medical reasonableness or necessity of the requested services. The elements of the coverage criteria are not satisfied.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care provided on March 8, 2021, by an OON provider.

You asked the Plan to pay for the subsequent nursing facility care. You say that a prior authorization was requested but the request was denied. You also say that that it was medically necessary for your provider to evaluate the enrollee's toe a week after nail removal. The Plan denied your request. The Plan says the care was delivered without proper prior authorization. The Plan also says that the services delivered were not urgent/emergent in nature and were not medically necessary.

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 the subsequent nursing facility care provided on March 8, 2021, by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for assistant at surgery services provided on April 13, 2021.
You asked the Plan to pay for the surgical assistant services. You say that the surgical assistant provided the services in the best interest of the enrollee for which he should not be denied payment. The Plan denied your request. The Plan says Medicare guidelines state that an assistant surgeon may not be paid for this procedure.
The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 38525. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for the surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for assistant at surgery services provided on April 13, 2021.
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 the enrollee needs a safe discharge plan and will benefit from admitting into LTACH setting and this is the safest setting. The Plan denied your request. The Plan says the stay is not medically necessary.
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 documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The clinical assessment in the case file does not support that the enrollee is reasonably expected to benefit from, and improve with, LTACH services. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0483) provided on June 30, 2020.
You asked the Plan to pay for drug testing. You say that these services must be performed in the laboratory. The Plan denied your request. The Plan says these services must be billed with the place of service were the sample was taken.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0483) provided on June 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services provided on June 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this type of provider is not eligible for payment.
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 assistant surgeon services provided on June 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99292) provided on February 7, 2021.

You asked the Plan to pay for critical care services. You say that this is documented in the records. The Plan denied your request. The Plan says the records do not support this code.

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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service.

We find that CPT code 99292 is not supported in the medical record. Specifically, the records do not show that more than 74 minutes were spent on critical care on this date of service. Billing an additional half an hour is not supported. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99292) provided on February 7, 2021.
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 all physicians involved with you concur that LTACH is the appropriate level of care for you. You state you are medically stable to be transfer to LTACH level of care at this time. The Plan denied your request. The Plan says the stay is not medically necessary.
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 you were admitted following cardiopulmonary arrest. You remain intubated with an inability to attempt weaning due encephalopathy. You are not neurologically stable. You continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 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 for the enrollee.
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 the enrollee's ongoing skilled therapy and nursing needs can be provided at a lower 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure, Non-ST-Elevation Myocardial Infarction, and a pulmonary embolism. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for total knee
arthroplasty (CPT code 27447), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you are requesting review of
denial of services. The Plan denied your request. The Plan says the enrollee is medically stable and has been
provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed
under CPT code 27447 is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only
List. The Plan states the procedure is currently approved as an ambulatory procedure and there is no
documentation provided to support the expectation the enrollee will require a greater than two (2) midnight
stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for
inpatient level of care can be performed on concurrent review with updated clinical information.
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 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 planned procedure listed under CPT code 27447 is not listed on the
CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no
documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The
record does not show that at the admitting physician reasonably expects that the enrollee's necessary hospital
care will 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 pre-approve the acute inpatient hospital care for total knee arthroplasty (CPT code
27447), for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on February 9, 2021.
You asked the Plan to waive the copayment for an emergency room visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for emergency care. You have been asked to pay a $35 copayment for an emergency room visit. The correct copayment has been applied to the services that were provided. An emergency room visit falls within the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an emergency room visit provided by a participating provider on February 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on April 5, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that this was preventative, and you will not pay for it. The Plan denied your request. The Plan says the correct copayment has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for outpatient diagnostic tests/diagnostic radiology. You have been asked to pay a $100 copayment for a CT scan. The CT scan that was provided was diagnostic in nature; therefore, the correct copayment has been applied. A CT scan falls within the outpatient diagnostic tests/diagnostic radiology benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided by a participating provider on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a GenVisc injection (J7320) for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication of improved pain and function of the knee due to the use of GenVisc.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.

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 injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the provider noted that it has been longer than 6 months since the member has received GenVisc. There is still no indication that there was improved pain and function of the knee due to the use of GenVisc. Medical records only note a cortisone injection administered to the right knee with an improved response. The review has determined that the documentation does not support that the GenVisc is medically reasonable and necessary for the enrollee. The documentation does not support that the GenVisc is safe and effective for the enrollee.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a GenVisc injection (J7320) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periapical x-ray, panoramic x-ray, and denture services you received on April 12, 2021.

You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services are not covered.

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 services are not among those covered under this benefit. The Plan covers only oral exams, cleanings, and bitewing x-rays. Periapical x-rays, panoramic x-rays, and denture services are not covered.

Therefore, we decided that the Plan does not have to pay for the periapical x-ray, panoramic x-ray, and denture services you received on April 12, 2021.