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

We decided that the Plan does not have to pay for the lab services provided on January 26, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 26, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the goal is strengthening the member so she may participate with basic self-care and return to home with family/caregiver support. The Plan denied your request. The Plan says that this member does not have complex nursing or medical needs requiring a resource intensive inpatient hospital setting.
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 a calcaneal fracture after a fall. The enrollee's medical conditions 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a cervical discography (62291) performed on January 13, 2021.
You asked the Plan to pay for a cervical discography. You say that the procedure at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met as the procedure at issue is experimental/investigational.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for cervical discography. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the clinical value and efficacy of intra-discal steroid injection has not been demonstrated in the peer-reviewed literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cervical discography have not been met. Therefore, we decided that the Plan does not have to pay for a cervical discography (62291) performed on January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 25, 2021.
You asked the Plan to waive the copayment for the office visit. You say that this was billed as an office visit, but this was an annual wellness exam. The Plan denied your request. The Plan says the copayment applied correctly.
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 $5 copayment for a primary care physician office visit. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The records show you were treated for anemia and derangement of lateral meniscus during the visit, which are not considered preventive services. 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 the office visit provided on January 25, 2021.
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 stay is medically necessary. The Plan denied
your request. The Plan says the enrollee has been in an intensive rehabilitation facility since June 8, 2021, after
suffering from a stroke. The Plan states the enrollee is progressing slowly with therapy and tolerating intensive
rehab programs. and the enrollee's doctor and therapists indicated they should continue the treatment plan the
enrollee is on and will continue to benefit from intensive rehabilitation three (3) hours per day five (5) times
per week.
The Plan states the appeal indicates the enrollee has been in the program for twenty (20) days and the enrollee's
progress has been complicated with acute urinary tract infections. The Plan states the enrollee will need a
longer than expected time in therapies to return to the community/home safely.
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 based on the medical records provided there is
documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and
judgment of a skilled professional nurse are required to safely and effectively provide medically necessary and
reasonable treatment. This patient does require skilled therapy services, i.e., the specialized skill, knowledge
and judgment of a qualified therapist are required to safely and effectively provide medically necessary and
reasonable treatment. Daily skilled services are required. This patient does not require the services on an
inpatient basis, only in a skilled nursing facility setting. Continued care in the acute inpatient rehabilitation
facility is appropriate (and endorsed by the health plan) until the patient is stable to transfer to a lower level of
care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: 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 need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
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. Our physician reviewer found that based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, you have not been shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the MammaPrint testing provided on September 28, 2020.
You asked the Plan to pay for the testing services. You say that the testing was instrumental in making critical decisions for the treatment of the enrollee. The Plan denied your request. The Plan says there is little data regarding gene testing with 4 or more lymph nodes.
The Plan must follow Medicare rules. Medicare rules say that MammaPrint testing is only covered under certain medical indications.
We looked at the file and Medicare rules. The medical records documented 6 of the enrollee's lymph nodes showing metastatic disease. The test is covered for up to 3 positive lymph nodes. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the MammaPrint testing provided on September 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 23, 2021 by a non-network provider.
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 rendered by a non-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 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 physician services provided on January 23, 2021 by a non-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97168) provided August 13, 2020.
You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records provided do not support the number of units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. We find that 4 units of CPT code 97168 are not supported in the medical record. The medical record only supports 1 unit of CPT code 97168. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97168) provided August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Sanexas neoGen-Series therapy, Vasopneumatic device
therapy, and subcutaneous injection of Nutri-Pharmaceutic blend provided October 16, 2020.

You asked the Plan to pay for Sanexas neoGen-Series therapy, Vasopneumatic device therapy, and
subcutaneous injection of Nutri-Pharmaceutic blend. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says the clinical value and effectiveness of the
services have not been demonstrated in the peer-reviewed literature.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for Sanexas neoGen-Series therapy, Vasopneumatic device therapy, and subcutaneous injection of Nutri-Pharmaceutic blend. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found these were experimental/investigational procedures that are not evidence based. The request is therefore deemed, 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 Sanexas neoGen-Series therapy, Vasopneumatic device therapy, and subcutaneous injection of Nutri-Pharmaceutic blend have not been met. Therefore, we decided that the Plan does not have to pay for Sanexas neoGen-Series therapy, Vasopneumatic device therapy, and subcutaneous injection of Nutri-Pharmaceutic blend provided October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the triamcinolone acetonide injection (J3300), ondansetron hydrochloride injection (J2405), midazolam hydrochloride injection (J2250), fentanyl citrate injection (J3010), and the low osmolar contrast material, iodine concentration (Q9967) provided on October 19, 2020 and December 15, 2020.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for each Medicare-covered Part B drug.
You have been asked to pay $123.90 (the Plan allowed amount of $619.52 x 20%) for the Medicare Part B drugs provided. 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 coinsurance for the triamcinolone acetonide injection (J3300), ondansetron hydrochloride injection (J2405), midazolam hydrochloride injection (J2250), fentanyl citrate injection (J3010), and the low osmolar contrast material, iodine concentration (Q9967) provided on October 19, 2020 and December 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Genesight testing (81479) provided on December 2, 2020.
You asked the Plan to pay for Genesight testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenomics (PGx) tests must demonstrate analytical validity, clinical validity, and clinical utility to be considered reasonable and necessary for coverage. This is demonstrated through a required technical assessment of the test. PGx tests are considered germline tests and must adhere to other relevant germline testing policies published by this contractor. We looked at the file and Medicare rules. The testing at issue has not undergone a technical assessment and is not covered by the Medicare contractor. Based on this information, we decided that Medicare rules for
coverage of Genesight testing have not been met. Therefore, we decided that the Plan does not have to pay for Genesight testing (81479) provided on December 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for knee fusion (27580) provided on January 16, 2021.
You asked the Plan to pay for knee fusion. You say that this procedure is documented. The Plan denied your request. The Plan says this code is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 27580 is arthrodesis, knee, any technique. We find that CPT code 27580 is not supported in the medical record. Specifically, the records do not show that arthrodesis was performed. Based on this information, we decided that Medicare rules for coverage of knee fusion have not been met. Therefore, we decided that the Plan does not have to pay for knee fusion (27580) provided on January 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on FEBRUARY 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
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 FEBRUARY 25, 2021.
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 December 10, 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 December 10, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95885, CPT 95908, CPT 95957) provided to the enrollee on December 1, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of the denied codes is: 

CPT 95885: 

limited needle electromyography, per each extremity with related paraspinal areas when performed,done with nerve conduction, amplitude and latency/velocity study; (listed separately in addition to code for primary procedure)


CPT 95908: 

nerve conduction studies for 3-4 studies CPT 95957: digital analysis of electroencephalogram (EEG) (for epileptic spike analysis) 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation submitted does not give the description of the billed codes; therefore, the codes cannot be confirmed. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for neurology services (CPT 95885, CPT 95908, CPT 95957) provided to the enrollee on December 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional physical therapy (PT) visits.
You asked the Plan to pre-approve additional PT visits. You say that the additional PT visits are medically necessary. The Plan denied your request. The Plan says six (6) additional PT visits are 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 six (6) 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 the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had prior therapy and the records do not demonstrate 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 by or under the supervision of a therapist. You have been instructed in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your 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 six (6) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional PT visits.