Persius/hicric huggingface dataset:
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 the admission. You say that this is medically necessary.The Plan denied your request. The Plan says admission to a SNF is medically necessary when all the required criteria is met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound care or other SNF level SN need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 the admission 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 has network providers available who can provide 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 medical services provided to the enrollee by an out-of-network provider on September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 panel rendered on February 21, 2020.You asked thePlan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, wedecided that the Plan does not have to pay forthe Guardant360 panel rendered on February 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebotox injections.You asked the Plan to pre-approvebotox. You say that the botox is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 botox. Our reviewer says that the medication is not medically necessary in this case. Our physician reviewer found review ofthe approved compendia does not support the simultaneous use of Botox and Aimovig for the prophylatic treatment of migraines.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of botox have not been met.Therefore, we decided that the Plan does not have to pre-approvebotox injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting, such as acute rehab facility, skilled nursing facility, nursing facility, or home care.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 does not require services at the LTACH that are not available at the acute care hospital where he/she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in thecurrent acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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 Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH) for the enrollee
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from December 3, 2019 through December 5, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would 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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from December 3, 2019 through December 5, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhysteroscopy (58558) and injections (J1885, J2250, J3010, J2405 and J2704) provided on February 12, 2020.You asked the Plan to pay forthe hysteroscopy and injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted 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 58558 is hysteroscopy, surgical; withsampling (biopsy) of endometrium and/or polypectomy, with or without D&C.The CPT Code Manual definition of code J1885 is injection, ketorolac tromethamine, per 15 mg.The CPT Code Manual definition of code J2250 is injection, midazolam hydrochloride, per 1 mg.The CPT Code Manual definition of code J3010 is injection, fentanyl citrate, 0.1 mg.The CPT Code Manual definition of code J2405 is injection, ondansetron hydrochloride, per 1 mg.The CPT Code Manual definition of code J2704 is injection, propofol, 10 mg.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 hysteroscopy and injections. Our reviewer says that CPT codes 58558, J1885, J2250, J3010, J2405 and J2704 do not meet criteria for billing or reimbursement consideration. Our reviewer found the record does not include documentation of a hysteroscopy or injections to support these codes. We looked at this coder's review, the file,and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the hysteroscopy and injections have not been met.Therefore, we decided that the Plan does not have to pay forhysteroscopy (58558) and injections (J1885, J2250, J3010, J2405 and J2704) provided on February 12, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that you require additional rehab.The Plan denied your request. The Plan says that daily skilled services are not required for your care.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 topre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam radiation therapy (PBRT) (77522).You asked the Plan to pre-approvePBRT. You say that the services are necessary.The Plandenied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 PBRT. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found to date, there are no compelling data to suggest that proton therapy is superior to or more beneficial than intensity-modulated radiation therapy/image-guided radiation therapy (IMRT/IGRT). The generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PBRT have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam radiation therapy (PBRT) (77522).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (HCPCS G0483) provided to the enrollee on February 24, 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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains 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 HCPCS code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed." 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 there are two signed and dated (10/21/19 and 11/18/19) provider orders, neither of which specifies the patient's name, diagnoses or medication history. No other medical history is submitted. No results of the ordered testing are submitted. The records do not support the coding of HCPCS G0483. 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 drug testing services (HCPCS G0483) provided to the enrollee on February 24, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided on February 8, 2020.
You asked the Plan to pay for the ambulance services. You say that you would like reconsideration because this is not a duplicate claim. The Plan denied your request. The Plan says that the primary diagnosis should not be duplicated as an additional or secondary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT codes A0427 and A0425 are supported in the record. Specifically, the submitted claim does not include a duplicate diagnosis code. Additionally, the Plan has not identified a diagnosis code which can only be used as a primary code. No rule or regulation has been cited to support that any of the reported diagnosis codes can only be used as a primary diagnosis. It is the burden of the Medicare Health Plan to substantiate the denial with medical evidence. Based on this information, we decided that Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has to pay for the ambulance services (A0427 and A0425) provided on February 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.
You asked the Plan to pre-approve the walk-in shower. You say that the enrollee has significant physical immobility due to severe juvenile rheumatoid arthritis. The Plan denied your request. The Plan says the requested service does not meet the definition of durable medical equipment and is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a walk-in shower.
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 the records provided support the need for LTACH care. The Plan denied your request. The Plan says the records do not indicate that it is medically necessary for the enrollee to be in an LTACH in place of an acute care hospital.
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 to the acute care hospital on June 3, 2020 with COvid-19, acute hypoxic respiratory failure, severe sepsis, CHF, and a cardiac arrest which resulted in anoxic brain injury. The enrollee has been on dialysis since June 20, 2020. A tracheostomy and a PEG tube have been placed. On June 28, 2020, the enrollee was critically ill and on full ventilator support. His prognosis was guarded, with a high probability of sudden clinically significant, life-threatening deterioration. The enrollee is receiving acute hospital care, and acute care services have not been denied. 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 he is currently receiving care. The clinical assessment does not indicate that the enrollee is likely to benefit from, and improve with, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe arthroscopy (29824) provided on July 10, 2020.You asked the Plan to pay forthe arthroscopy. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service 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 29824 is arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) .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 arthroscopy. Our reviewer says that CPT code 29824 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not indicate that arthroscopic claviculectomy including distal articular surface was performed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the arthroscopy have not beenmet.Therefore, we decided that the Plan does not have to pay forthe arthroscopy (29824) provided on July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urgent care services provided on October 26, 2019.
You asked the Plan to pay for the urgent care services. The Plan denied your request. The Plan says you must receive care from a network provider and in most cases, care received from an out-of-network provider will not be covered, except for the following: emergency care or urgently needed service and needed medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care (authorization is required).
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 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 urgent care services provided on October 26, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe removal of posterior segmental instrumentation (22852) provided on February 18, 2020.You asked the Plan to pay forthe removal of posterior segmental instrumentation. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service 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 22852 is removal of posterior segmental instrumentation.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 removal of posterior segmental instrumentation. Our reviewer says that CPT code 22852 does not meet criteria for billing and reimbursement consideration. Our reviewer found this code should not be reported separately as it is inclusive with CPT code 22845.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the removal of posterior segmental instrumentation have not been met.Therefore, we decided that the Plan does not have to pay forthe removal of posterior segmental instrumentation (22852) provided on February 18, 2020.