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

We decided that the Plan does not have to pay for the annual nursing facility assessment (99318) provided on February 2, 2021.
You asked the Plan to pay for the annual nursing facility assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99318 denied for exceeding the allowed time span of once every 365 days.
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 99318 is evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient's facility floor or unit. We find that CPT code 99318 is not supported in the record. Specifically, this code may only be billed once per 365 days. The record indicates that this CPT code was billed for this member on February 19, 2020. Based on this information, we decided that Medicare rules for coverage of the annual nursing facility assessment have not been met. Therefore, we decided that the Plan does not have to pay for the annual nursing facility assessment (99318) provided on February 2, 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 the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 the enrollee's medical conditions are stable and there are not complex nursing or rehabilitation needs. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex device.
You asked the Plan to pre-approve a Vertiflex device. You say that the requested Vertiflex device is medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device 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 Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with chronic back pain. The Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. The request is not medically necessary 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 a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve keytruda (J9271).
You asked the Plan to pre-approve keytruda. 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 anti-cancer 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 keytruda. Our reviewer says that this drug is not medically necessary. Our physician reviewer found the requested drug is not FDA-approved for the enrollee-s diagnosis and its use is not supported in any of the major drug compendia or clinical research.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of keytruda have not been met. Specifically, the requested drug is not FDA approved for the enrollee's diagnosis or supported by any of the major drug compendia. This means the drug is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve keytruda (J9271).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 10, 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 if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that providers must report services correctly. 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 requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found it is noted multiple attempts were made to obtain additional information from the provider. The review has determined that the laboratory services provided to the enrollee on December 10, 2020 were not medically necessary or reasonable. The denied codes remain not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical
documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also,
the laboratory results submitted indicate the specimen was collected on 12/10/2020 and received by the lab on
12/14/2020. Of note, the enrollee resides in Utah and the billing laboratory is in Florida; therefore, the billed
codes cannot be verified.
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 laboratory services provided to the enrollee on December 10, 2020.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
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 you medical conditions are stable and here are no complex nursing or rehabilitation needs. you do require physical and occupational therapy, but there is no documented need for an intensive 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. 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 laboratory services rendered on November 30, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluations, first intraoral periapical x-ray, panoramic x-ray, and prophylaxes provided from March 18, 2019, to September 19, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluations, first intraoral periapical x-ray, panoramic x-ray, and prophylaxes. You say that you would like the enrollee to be reimbursed for their out of pocket dental expenses. The Plan denied your request. The Plan says these services were rendered by a non-participating provider.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluations, first intraoral periapical x-ray, panoramic x-ray, and prophylaxes provided from March 18, 2019, to September 19, 2019 by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transportation to the US border, on April 18, 2020.
You asked the Plan to pay for the ambulance transportation. The Plan denied your request. The Plan says Transportation back to the United States from another country is not covered.
The Plan contract says transportation back to the United States from another country is not covered.
We looked at the file and the Plan's rules. The Plan does not provide coverage for transportation back to the United States from another country. Therefore, we decided that the Plan does not have to pay for ambulance transportation provided from Mexico to the US/Mexican border, on April 18, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care.

You asked the Plan to pay for acute inpatient hospital care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary and there are providers in-network who can perform this service.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found you are not expected to require hospital services that would cross two midnights, as you are receiving a low risk procedure. There is also no indication that you will require a specific surgeon for this procedure and receiving it out-of-network is 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 your medical condition is stable and you have no complex nursing or rehabilitation needs. You do require physical and occupational therapy, but there is no documented need for an intensive 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. Specifically, medically necessary services can be provided at a lower level of care. This means admission into an IRF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your main diagnosis is peripheral vascular disease. You are currently medically stable. At the current level of function, given your inability to follow commands and inability to participate in therapies, you do not require daily skilled therapy services on an inpatient basis in a SNF. The patient is stable with no new medical problems, functional level as described above he will not participate or benefit from daily skilled therapies in an inpatient setting for an justify an admission to an SNF. The enrollee's needs could be safely and effectively addressed in a long-term care setting. Basically, his care is custodial. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177).

You asked the Plan to pre-approve a CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177). You say that the requested CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177) are medically necessary. The Plan denied your request. The Plan says that the requested CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177) are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically 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 a CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177). Our reviewer says that the requested CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177) are medically necessary. Our physician reviewer found the enrollee underwent surgical resection of a Stage IIIB sigmoid colon cancer on 10/31/16 and completed adjuvant chemotherapy in May 2017. Per NCCN guidelines (colon cancer 2.2021 page COL-8), a CT scan of the abdomen/pelvis and a CT scan of the chest are recommended every 6-12 months for 5 years. As the enrollee has been doing this, this will allow repeat CT scans through December 2021. The requested CT scans are 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 a CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177) have been met. Therefore, we decided that the Plan has to pre-approve a CT scan of the chest (71260) and CT scan of the abdomen/pelvis (74177).

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you have stabilized medically and is ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near her baseline and she can receive services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services beyond August 6, 2021.

You asked the Plan to pre-approve a continuation of SNF services. You say that you are nowhere ready for discharge. The Plan denied your request. The Plan says your current level of function is stabilized at the prior level of function with regard to mobility and transfer.

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 a continuation of SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of August 6, 2021 the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or ADLs. The member did not require skilled therapy to establish a safe and effective maintenance program. She did not have any parental medications, complex wound care or nutrition given via a feeding tube. The member received skilled care and improved, however her function had plateaued by August 6, 2021 and she did not require any further inpatient skilled rehab services. The member's function was at or near her prior level of function and she could be discharged to a lower level of care for further services. As of August 6, 2021, the member required custodial services. The denial for further inpatient skilled care is upheld. 

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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services beyond August 6, 2021.