Persius/hicric huggingface dataset:
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 member will need additional occupation and physical therapy. The Plan denied your request. The Plan says that the member's care needs can 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. 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 surgical repair of a distal femur fracture. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (CPT code 81455) provided to the enrollee on January 27, 2021.

You asked the Plan to pay for the laboratory testing. You say that this was for comprehensive genomic profile testing for the enrollee with advanced cancer ad this is used to help determine treatment. The Plan denied your request. The Plan says this is not covered by Medicare.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary and screening testing. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (CPT code 81455) provided to the enrollee on January 27, 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 these services are medically necessary. The Plan
denied your request. The Plan says that this request exceeds the member's needs.
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
are generally medically stable and there is no evidence of complex medical issues that require monitoring by an
inpatient physical medicine and rehab physician three times per week.
While you may benefit from continuing physical and occupational therapy, there is no evidence of need for an
intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care at your current mobility with supervision level. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on December 11, 2020.

You asked the Plan to pay for the initial hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.

We find that CPT code 99223 is not supported in the medical record. Specifically, the requirements for billing code 99223 is a comprehensive history, comprehensive examination, medical decision making of high complexity. The documentation only supports a comprehensive history, comprehensive examination, and medical decision making of moderate complexity. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the initial hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care services coded 99223 provided on December 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 27, 2021, through January 31, 2021.
You asked the Plan to pay for the subsequent hospital care. 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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of 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 responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 subsequent hospital care. Our reviewer says that CPT code 99232 does not meet criteria for billing or reimbursement consideration. Our reviewer found Evaluation and Management visits for dates of services billed does not support CPT 99232 level. History and exam are problem focused with straightforward medical decision making. CPT 99231 is a more appropriate code to report for this service. 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 subsequent hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided on January 27, 2021, through January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the lift chair purchased on January 5, 2021, from a non-certified Medicare provider.
You asked the Plan to reimburse for the DME. You say that you chose to purchase a lift chair as opposed to going to the care center. You state that you saved money by not going to the care center and that you needed the lift chair. The Plan denied your request. The Plan says you purchased the DME and received an item from a non-certified provider.
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 reimburse 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 reimburse for these items/services. Therefore, we decided that the Plan does not have to reimburse for the lift chair purchased on January 5, 2021, from a non-certified Medicare provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth services (CPT code 99443) provided on January 4, 2021, and February 22, 2021.
You asked the Plan to waive the copayment for the telehealth services. You say that you do not want to go to the doctor's office and telehealth is very helpful. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received the telehealth services (CPT code 99443) on January 4, 2021, and February 22, 2021. You were asked to pay a $15 copayment for each covered visit or consultation in an outpatient location with a specialist. 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 telehealth services (CPT code 99443) provided on January 4, 2021, and February 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a second preloaded injector to deliver an additional anterior segment aqueous drainage device.
You asked the Plan to pre-approve insertion of a second preloaded injector to deliver an additional anterior segment aqueous drainage device. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that there is no additional payment for multiple stents (so-called "dosing"), regardless of method, since a statistical benefit has not been demonstrated (27), especially in conjunction with cataract surgery.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of a second preloaded injector to deliver an additional anterior segment aqueous drainage device have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of a second preloaded injector to deliver an additional anterior segment aqueous drainage device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced leg pump device to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an advanced leg pump device to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.

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 an advanced leg pump device to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you no longer require daily skilled services and the continuation of SNF 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for 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-approve continued skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care in order to get back your normal state of health. You state you are currently in the hospital where they only give you a twenty (20) minute rehabilitation session a day. You state with IRF care you would get at least three (3) hours of rehabilitation. The Plan denied your request. The Plan says the stay 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 do not meet Centers for Medicare and Medicaid Services (CMS) criteria for IRF admission. You are medically stable with no evidence of need for supervision by acute Physical Medicine and Rehabilitation (PMR) physician. You may benefit from further physical therapy (PT) and occupational therapy
(OT) but do not require an intensive therapy program 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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.

You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation is needed. The Plan denied your request. The Plan says the benefit has been exhausted.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way transportation trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of an
intraocular lens prosthesis.

You asked the Plan to pre-approve extracapsular cataract removal with insertion of an intraocular lens
prosthesis. You say that the services are necessary. The Plan denied your request. The Plan says medical
necessity has not been established. Therefore, coverage criteria have 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 extracapsular cataract removal with
insertion of an intraocular lens prosthesis. Our reviewer says that the requested items/services are not
considered medically reasonable and necessary in this case. Our physician reviewer found the requested service
is not medically necessary and reasonable, as defined by Medicare rules, for the enrollee. The elements of the
coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of extracapsular cataract removal with insertion of an intraocular lens prosthesis
have not been met. Therefore, we decided that the Plan does not have to pre-approve extracapsular cataract removal with insertion of an intraocular lens prosthesis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ketamine infusions.
You asked the Plan to pre-approve Ketamine infusions. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Ketamine infusions. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the documentation does not support that the Ketamine infusions is medically reasonable and necessary for the enrollee. The documentation does not support that the Ketamine infusions is safe and effective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine infusions have not been met. Therefore, we decided that the Plan does not have to pre-approve Ketamine infusions.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on August 5, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says Medicare billing criteria are not met. Maximus overturned the Plans denial. The Plan
requested a reopen and stated Maximus did not apply the correct criteria.

The Plan says that this claim denied because the provider has billed inappropriately. The Plan states this claim
represents part of an expanded pharmacogenomic panel and they are not supported. The Plan states per Local
Coverage Article (A57503) titled "Billing and Coding MolDX: Testing of Multiple Genes," a panel constitutes
a single procedural service. Only one code is submitted per panel. The Centers for Medicare & Medicaid
Services (CMS) National Correct Coding Initiative Coding Policy Manual for Medicare Services states "If one
laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory
shall report only one unit of service. If no CPT code accurately describes the procedure performed, the
laboratory should report code 81749.

The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case, this claim
cannot be paid as billed due to an error with the type of codes submitted for payment of this type of service.
Medicare billing criteria were not met. Therefore, we decided that the Plan does not have to pay for laboratory
services provided on August 5, 2020.