Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be received in another 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 above. 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 IRF admission is not medically necessary based on her current functional status and medical stability. As per Medicare guidelines, he is expected to make significant gains in a predicted period of time and it is unlikely that he can do that with current functional status. He does not need 3 hours of therapy as he cannot tolerate with easy fatigability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says you can safely receive necessary services at a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 requestto 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 records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed and a lower level of care. A longer duration of therapy may be more appropriate and it is not clear that you would be able to fully benefit or participate in an IRF level of care.We looked at this physician'sreview, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 30, 2019.
You asked the Plan to pay for the drug testing. 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 a covered benefit.
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 G0482 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; 15-21 drug class(es), including metabolite(s) if performed. We find that CPT code G0482 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician/lab requisition or medical records signed by the ordering physician stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0482 provided on August 30, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for genetic testing codes 81202, 81404, 81405, and 81408. We decided that the Plan does not have to pay for genetic testing codes 81272 and 81314.
You asked the Plan to pay for genetic testing. You say that the in-network treating physician ordered these tests because they were medically necessary to provide the best care for the enrollee. The Plan says that the denial of payment for these services is correct, because testing codes 81202, 81404, 81405, and 81408 are statutorily excluded from Medicare coverage and testing codes 81272 and 81314 were not medically necessary.
We decided that the Plan has to pay for genetic testing codes 81202, 81404, 81405, and 81408.
The Plan follows Medicare rules. Medicare rules say that procedure codes 81202, 81404, 81405, and 81408 were covered by Medicare for date of service August 25, 2019. These tests did not have any coverage limitations based on procedure to diagnosis code relationships.
The Plan denied payment for these tests on the basis that they were statutorily excluded from Medicare coverage. However, according to Medicare rules these tests were covered by Medicare for date of service August 25, 2019 with no coverage limitations based on diagnosis. These tests were ordered by the enrollee's in-network treating physician. Therefore, we decided that the Plan has to pay for genetic testing codes 81202, 81404, 81405, and 81408.
We also decided that the Plan does not have to pay for genetic testing codes 81272 and 81314.
The Plan follows Medicare rules. Medicare rules say that procedure codes 81272 and 81314 were covered by Medicare for date of service August 25, 2019. However, these tests were only covered when billed with certain specific diagnosis codes which do not include diagnosis codes C56.2, C78.6, C79.89, or Z80.41.
The Plan denied payment for these tests on the basis that they were not medically necessary. According to Medicare rules, these tests were not covered by Medicare for the diagnosis codes billed on this claim. Therefore, we decided that the Plan does not have to pay for genetic testing codes 81272 and 81314.
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 for an injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches provided on September 18, 2019.You asked the Plan to pay for the injection. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 an injection of anesthetic agent (nerve block), diagnostic or therapeutic procedures on the paravertebral spinal nerves and branches provided on September 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided October 14, 2019.You asked the Plan to pay forthe orthosis. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelinesThe Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) knee orthosis (L1833) and suspension sleeve (L2397) provided October 14, 2019.
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 admission. You say that you are appealing based on medical necessity. The Plan denied your request. The Plan says the denial of authorization for SNF service is correct, because the enrollee revoked hospice on February 13, 2020 and therefore the Plan will not begin covering services again until March 1, 2020.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.

The enrollee ended Medicare Hospice benefits on February 13, 2020. The Plan will not be responsible for coverage of services until March 1, 2020. Therefore, we decided that the Plan does not have to pre-approve admission to a Skilled Nursing Facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you have a high chance of getting septic again since the toe is bleeding again.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-approvefoot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided on August 7, 2019.
You asked the Plan to pay for the orthosis. You say that the documentation and records show medical necessity from the ordering physician. The Plan denied your request. The Plan says the records provided do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided on August 7, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan of the whole body (78816) to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea PET CT scan of the whole body. 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 this service. Therefore, coverage criteria has 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-approvea positron emission tomography (PET)with concurrently acquired computed tomography (CT) scan of the whole body (78816) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on May 22,
2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary.
The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833)
provided to the enrollee on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forbilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on August 30, 2019.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable todiscover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit isnot a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forbilateral knee orthoses (L1851) and suspension sleeves (L2397) provided to the enrollee on August 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepercutaneous lumbar decompression (0275T).You asked the Plan to pre-approvepercutaneous lumbar decompression. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee is not enrolled in a clinical study.The Plan must follow Medicare rules. Medicare rules say that this procedure is covered for beneficiaries with lumbar spinal stenosis who are enrolled in an approved clinical study.We looked at the file and Medicare rules. Specifically, the documentation submitted does not show that the enrollee is enrolled in an approved clinical study. Based on this information, we decided that Medicare rules for coverage of percutaneous lumbar decompression have not been met.Therefore, we decided that the Plan does not have to pre-approvepercutaneous lumbar decompression (0275T)
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit (99282) provided September 12, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that the hospital provided poor service and the copayment should be waived. The Plan denied your request. The Plan says the correct cost share was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the Emergency Care 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 copayment for an emergency room visit (99282) provided September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric tablets.
You asked the Plan to pre-approve Uloric tablets. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Uloric tablets are not covered under the enrollee's Medicare Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Uloric tablets.
Benefits for Uloric tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health therapy services.
You asked the Plan to pre-approve continued services. You say that you do not have full range of motion to drive a car. The Plan denied your request. The Plan says you are not homebound.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued services. Our physician reviewer found that you are independent with ambulation of 200 feet with no assistive device, and supervision to minimal assist with transfers and bed mobility. Range of motion (ROM) on the upper extremity has improved after re-initiation of physical and occupational therapy. You are functioning at a high level, and have made improvement with ROM, mobility, and activities of daily living. At this point, you can be safely transitioned to a home program. The medical records do not support the skill of a therapist is required to treat your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for orthopedic services (CPT 22853) provided to the enrollee on August 15, 2019.
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 procedure code 22853-76 is 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 22853 is "insertion of a interbody biomechanical device(s) (synthetic cage, mesh) with integral anterior instrumentation for device (screws, flangers) when performed, to intervertebral disc space in conjuction with interbody arthrodesis, for each interspace (listed separately in addition to code for primary procedure)." 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 coded correctly. Our physician reviewer found the code in question was charged twice (CPT 22853, CPT 22853.76). The documentation indicates that only one disc space was involved. The documentation does not note that the procedure was repeated by the same surgeon on the same day. Therefore, the billing of two units is not supported and the use of the 76 modifier is not supported. 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 orthopedic services (CPT 22853) provided to the enrollee on August 15, 2019.