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

We decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central venous catheter (37230) provided July 11, 2020.
You asked the Plan to pay for the insertion of non-tunneled centrally inserted central venous catheter. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the services billed are not supported by the medical records submitted.
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 36556 is insertion of non-tunneled centrally inserted central venous catheter.
We asked our coder 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 insertion of non-tunneled centrally inserted central venous catheter. Our reviewer says that the CPT code as billed is not supported by the provided medical documentation. Our physician reviewer found the enrollee is a 69-year-old female who received services on July 11, 2020, for CPT 36556 Insertion of non-tunneled centrally inserted central venous catheter. Documentation submitted was reviewed and the criteria have not been met. In this case, the procedure report does not document a catheter inserted through one of the central veins in the neck, chest or groin, therefore this procedure cannot be confirmed as performed. We looked at the coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of non-tunneled centrally inserted central venous catheter have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of non-tunneled centrally inserted central venous catheter (37230) provided July 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic services provided to the enrollee on November
20, 2020, by an out-of-network provider.
You asked the Plan to pay for the diagnostic services. You say that the claim should be paid. The Plan denied
your request. The Plan says this provider is out-of-network, the services were not referred by a network
provider, and the services were not urgent or emergent, nor were they approved in advance.
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 diagnostic services provided to the enrollee on
November 20, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute setting.
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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 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 long term acute care hospital (LTACH) services.
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 enrollee needs 24/7 care which cannot be provided at a home setting. The Plan denied your request. The Plan says the stay is not medically necessary based on the criteria.
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 the member has stabilized medically and is ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy services on a daily basis. The member is 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. The member does not have any parental medication; complex wound care or nutrition given via a feeding tube. The member is medically stable without any acute exacerbations of chronic medical problems. The member's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services 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 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: 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 until you get your strength back.
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 although there are identifiable skilled therapy
service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled
nursing or therapy services on a daily basis. In conclusion, 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 admission to a skilled nursing facility (SNF).
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 you need maximum assistance for your activities of daily living, you cannot feed yourself, you cannot take a bath on your own, you do not have a caregiver at home because your family has to work, you cannot walk on your own and you are only able to stand for about thirty (30) seconds without the therapist holding you. The Plan denied your request. The Plan says the stay is 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 based on the medical records provided there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do 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 not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 the patient will benefit from the care that can be
provided at an IRF. 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 the patient was admitted for seizures, left arm weakness, and a headache. 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. In conclusion, 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.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99152) provided December 24, 2020.
You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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 code 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time, patient age 5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation does not show the presence of a trained observer. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided December 24, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lumbar spinal surgery and was treated after surgery for confusion attributed to medication effect. Your medical conditions are stable.
There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0801).
You asked the Plan to pre-approve a power scooter (K0801). You say that the requested power scooter (K0801) is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested power scooter (K0801).
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 power scooter (K0801). Our reviewer says that the enrollee does not meet criteria for the requested power scooter (K0801). Our physician reviewer found the documentation indicates the enrollee has a mobility deficit that impairs mobility related activities of daily living (MRADLs) in the home and is not ameliorated by a walker, cane, manual wheelchair due to shortness of breath, back pain, right knee giving out. The documentation does not reveal that the enrollee can safely operate the requested K0801 due to loss of consciousness and due to inability to safely navigate the home due to the large turning radius. The criteria per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33789) have not been met for the requested K0801. 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 power scooter (K0801) have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0801).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services (CPT code(s): 95938-TC, 95861-TC, 95957-TC) provided to the enrollee on January 12, 2021.
You asked the Plan to pay for the medical services. You say that the provider is a legal mobile unit company that employs certified technicians to perform IOM services and that the technician performing the IOM services during a surgical procedure is at all times under the direction of the licensed neurologist, who is supervising the surgery. The Plan denied your request. The Plan says the claim was submitted with a provider not eligible for Medicare payment. 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 medical services have not been met. Medicare does not recognize you as a physician or non-physician practitioner; therefore, you are not allowed to bill directly for the services performed. The enrollee is not responsible for payment. Because the claim was not billed in accordance with CMS guidelines, no payment was made on this claim. Therefore, we decided that the Plan does not have to pay for the medical services (CPT code(s): 95938-TC, 95861-TC, 95957-TC) provided to the enrollee on January 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing provided on December 15, 2020.
You asked the Plan to pay for the testing services. You say that the test provides a more accurate prediction of the enrollee's medication response. The Plan denied your request. The Plan says the test is not covered by Medicare.
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. There is insufficient evidence to support widespread use of combinatorial pharmacogenetic decision support tools at this point in time. 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 GeneSight testing provided on December 15, 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 these services are medically necessary. The Plan denied your request. The Plan says that your care needs can continue to be met in the skilled nursing facility 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. You do not require the intensity of services provided at an IRF.
Specifically, you are not 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the neurology visit to be performed by an out-of-network
provider.
You asked the Plan to pre-approve the neurology visit. You say that the services are necessary. The Plan denied
your request. The Plan says there are in-network providers that can render the 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
the neurology visit to be performed by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the initial observation care visit provided on January 4, 2021.
You asked the Plan to pay for the initial observation care visit. You say that the medical record supports CPT code 99220. The Plan denied your request. The Plan says that no prior authorization was obtained.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. The medical record shows this visit seemed necessary to evaluate the enrollee's emergency condition. Therefore, we decided that the Plan has to pay for the initial observation care provided on January 4, 2021.
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.