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.

You asked the Plan to pre-approve IRF care. You say that the records provided support the need for IRF care. The Plan denied your request. The Plan says the records do not show that the enrollee needs an intensive program with a team of health care professionals and doctors that specialize in complex medical needs, as well as rehab. The Plan says that the records do not show that the enrollee can do 3 or more hours per day of skilled therapy for at least 5 days a week.

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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a cervical fracture and was discharged to a skilled nursing facility where he is receiving physical therapy services. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee 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 enrollee 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance, half leg (E0673) provided July 10, 2020.

You asked the Plan to pay for the pneumatic appliance. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says this service is not covered by Medicare. Payment for this service would have been included in the facility DRG or PPS prospective payment.

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 enrollee used the equipment in the facility during and/or after surgery. A pneumatic compression device and/or supplies is not covered by Medicare for deep vein thrombosis during and/or following surgery, at home, or in any setting. Payment for this service would have been included in the facility DRG or PPS prospective payment. Payment for this service is the responsibility of the facility or hospital that provided the surgery. As a non-covered service, it is not a benefit when ordered by either a contracted or a non-contracted provider. Based on this information, we decided that Medicare rules for coverage of the pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to pay for segmental gradient pressure pneumatic appliance, half leg (E0673) provided July 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion to be performed by an out-of-network tertiary care provider.

You asked the Plan to pre-approve the medical services. You say that you need a clearer prognosis and that you have only been given the runaround in regard to how long you are expected to live. The Plan denied your request. The Plan says this is not medically necessary as there is available care in-network including a second opinion.

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 provider at issue in this case is not a network provider with the Plan. 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 medical services. Our physician reviewer found other urology oncologists that were in-network were offered. According to the provided documentation, you required a second opinion of a urology oncologist to discuss treatment options and prognosis.

There was no indication that this could not be completed effectively with one of the available in-network physicians with this specialty.

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 medical services have not been met.

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 the medical services. Therefore, we decided that the Plan does not have to pre-approve a second opinion to be performed by an out-of-network tertiary care provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-ofnetwork
provider.

You asked the Plan to pre-approve the medical services. You say that the services are necessary. The Plan
denied your request. The Plan says the records received do not show a medical need as to why the enrollee
cannot get this vascular imaging and intervention from a provider in the enrollee's plan network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to 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 medical services to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot inserts (CPT code L3000).
You asked the Plan to pre-approve the foot inserts. You say that you have extreme pain and difficulty walking because of your planter facial fibromatosis. You state each day without a orthotic shoe insert that your doctor recommends your condition worsens. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot inserts (CPT code L3000).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tempus gene panel testing provided on December 14, 2020.

You asked the Plan to pay for the testing services. You say that the testing will guide appropriate medical management of the enrollee. The Plan denied your request. The Plan says service providers should use CPT code 81479 for the entire multi-test panel.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We looked at the file and the rules. The claim provided does not show that the gene panel was billed with the appropriate code. 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 Tempus gene panel testing provided on December 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 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 enrollee is not medically stable for transfer to
another level of care currently. The Plan says that the enrollee can stay in the hospital to finish your treatments.

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 is not medically stable for transfer. There is no documentation provided
necessitating admission to a LTACH. 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. 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 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 Plan
does not have to pre-approve LTACH services.
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 enrollee is medically stable and that staying
longer in the hospital will put her at risk of not recovering or gaining mobility and independence. The Plan
denied your request. The Plan says the records do not show that the enrollee requires the services of a rehab
doctor three times per week. The Plans says that the enrollee does not require the services of a specialized
rehab team. The Plan says that the enrollee can safely receive the services needed 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. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for cervical decompression and fusion for a C2 fracture. The enrollee's medical conditions are
stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation
therapy program. The enrollee 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 enrollee 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.

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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not require daily skilled nursing and/or skilled therapy 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 admission have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
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 enrollee is receiving appropriate inpatient acute care and does not require transfer to an LTACH.
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 there is no documentation provided necessitating admission to a LTACH. 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 he/she is currently receiving care. 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 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 Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmic biometry services (CPT 92136) provided to the
enrollee on October 9, 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 per the 2020 National Physician Fee Schedule, this code has a bilateral indicator of 2.

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 92136 is "ophthalmic biometry by partial coherence
interferometry with intraocular lens power calculation."

We asked our coding 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 coding reviewer found the
requested code has a MUE indicator of 2 for bilateral procedures. In this case, the requested service was billed
separately for each side. The requested code has a MUE of 2 for bilateral procedures. The requested service is
not billed properly. Payment for the requested service as billed cannot be recommended.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmic biometry services (CPT 92136) provided to the enrollee on October 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for a surgical procedure (54161) provided on December 3, 2020.

You asked the Plan to waive the co-payment for a surgical procedure. You say that the claim did not process correctly. You also say that the services were of medical necessity. The Plan denied your request. The Plan says the co-payment you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 co-payment for outpatient hospital services.

You have been asked to pay a $275 co-payment for a surgical procedure. The records show that you had a surgical procedure performed in an in-network, outpatient facility. The EOC confirms that $275 is the required co-payment for this service. A surgical procedure falls within the outpatient hospital services benefit category. 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 co-payment for a surgical procedure (54161) provided on December 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the 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 skilled nursing facility setting. Services in the home with home health care appears 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 SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95938, CPT 95868, CPT 95927,
CPT 95870) provided to the enrollee on November 13, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the records do not support the services billed, as the billed place of service is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of the denied codes is:

CPT 95938:

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites,
recording from the central nervous system

CPT 95868: 

Needle electromyography; cranial nerve supplied muscles, bilateral 

CPT 95927: 

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 

CPT 95870: 

Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral) 

We asked our coding 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 coding reviewer found per CMS "For services furnished in a mobile unit are often provided to serve and entity for which another POS code exists. When this is the case, the POS for that entity should be reported. For example, a mobile unit may be sent to a facility. Since the mobile unit is serving an entity for which a facility POS already exists, the POS code 21 (inpatient-hospital) for that location should be reported. However, if the mobile unit is not serving an entity which could be described by an existing POS code, report POS 15 (mobile unit)". The documentation submitted does not support neurology testing was not serving a facility, therefore, the TC modifier would not be covered. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for neurology services (CPT 95938, CPT 95868, CPT 95927, CPT 95870) provided to the enrollee on November 13, 2020.