Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xgeva (J0897).

You asked the Plan to pre-approve Xgeva. You say that the enrollee has tried and failed Dexamethasone. The Plan denied your request. The Plan says step therapy rules for the requested drug have not been met.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Xgeva. Our reviewer says that the requested treatment is not medically necessary. Our physician reviewer found that the Plan requires a trial of drugs Pamidronate and Zoledronic acid before they will approve the requested drug. The enrollee has not tried and failed the required drugs. The record does not contain sufficient documentation to support that the Plan's required drugs would likely be less effective and/or have adverse effects 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 Xgeva have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Xgeva (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray of lower and sacral spine, 2-3 views (CPT code 72100), application of electrical stimulation (CPT code 97014), and new patient office or other outpatient visit, 15-29 minutes (CPT code 99202) provided on January 22, 2021, by a chiropractor.

You asked the Plan to pay for the services. You say that in the EOC there is a $20 copayment for chiropractor in-network or out-of-network. The Plan denied your request. The Plan says these services were received from a chiropractor. The Plan states only services covered for chiropractic care is manual manipulation of the spine to correct subluxation (when one or more of the bones of the enrollee's spine move out of position).

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for x-ray of lower and sacral spine, 2-3 views (CPT code 72100), application of electrical stimulation (CPT code 97014), and new patient office or other outpatient visit, 15-29 minutes (CPT code 99202) provided on January 22, 2021, by a chiropractor.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (CPT 97110) provided to the enrollee on August 25, 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 code is not appropriate for 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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility." 

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 medical records document that service was performed in a home health or hospice setting. CPT 97110 is not the most appropriate code to use to bill this service, therefore, this service is not eligible for reimbursement consideration.

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 physical therapy services (CPT 97110) provided to the enrollee on August 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the intermittent limb compression device (E0676) provided on October 12, 2020.
You asked the Plan to pay for the intermittent limb compression device. You say that you would like reconsideration because this equipment is medically necessary. The Plan denied your request. The Plan says the billed supply is not a Medicare covered benefit.
The Plan follows Medicare rules. Medicare rules say that items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit. 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 intermittent limb compression device. Our reviewer says that the member does not meet Medicare coverage criteria for the billed equipment.
Our physician reviewer found based on the medical records provided there is documentation that this pneumatic compression device is being requested to prevent venous thromboembolism. 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 intermittent limb compression device have not been met. Therefore, we decided that the Plan does not have to pay for the intermittent limb compression device (E0676) provided on October 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve kyphoplasty services (22514, 22515).
You asked the Plan to pre-approve kyphoplasty services. You say that this is medically necessary. The Plan denied your request. The Plan says medical necessity criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that the kyphoplasty services are subject to the criteria listed 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 kyphoplasty services. Our reviewer says that the requested service does not meet the relevant Medicare criteria for coverage. Our physician reviewer found the criteria for kyphoplasty has not met. The magnetic resonance imaging does not show any evidence of acute compressions fractures that are less than 6 weeks old as specified by 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 kyphoplasty services have not been met. Therefore, we decided that the Plan does not have to pre-approve kyphoplasty services (22514, 22515).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing provided on November 3, 2020.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because
this testing is a Medicare covered benefit. The Plan denied your request. The Plan says Guardant360 testing is
not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Guardant260 testing may be covered when tissuebased
CGP is not feasible or when NSLC tissue-based CGP has shown no actionable mutations.

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 Guardant360 testing. Our reviewer says
that the member does not meet criteria for coverage of Guardant360 testing. Our physician reviewer found the
documentation does not support that tissue-based comprehensive genomic profiling is infeasible or has shown
no actionable mutations.

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 Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing provided on November 3, 2020.
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 the enrollee requires 15 hours of therapy a week to return to independence. The Plan denied your request. The Plan says it is not reasonable to expect the enrollee will be able to actively participate in the intensity of services of an IRF.
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 physician reviewer found that the enrollee was admitted to the acute care hospital for a hemorrhagic stroke. His medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that he will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. He does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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 a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says you do not have daily skilled therapy needs that can only be provided on an inpatient basis in a SNF setting.
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 physician reviewer found that you are at a supervision assist level for standing up, standby assist for walking using a rolling walker, and standby assist for returning to bed. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 cannot walk without assistance. The Plan denied your request. The Plan says it is not reasonable to expect that you will be able to fully benefit from the intensity of services of an IRF.
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 physician reviewer found that you were admitted to the acute care hospital for a cervical spine fusion. Your medical conditions are stable. There are no complex nursing needs. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. You do require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services described by current procedural terminology (CPT) code 27470 provided on June 22, 2020.

You asked the Plan to pay for CPT code 27470. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 27470.

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 27470 is Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression technique).

We find that CPT code 27470 is not supported in the medical record. Specifically, CPT code 27470 was not documented in the narrative of the operative report. Based on this information, we decided that Medicare rules for coverage of CPT code 27470 have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services described by current procedural terminology (CPT) code 27470 provided on June 22, 2020.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for a sinus endoscopy (31253) provided on August 31, 2020.
You asked the Plan to pay for a sinus endoscopy. You say that this code is supported. The Plan denied your request. The Plan says that this procedure is not documented.
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 31253 is nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when 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 a sinus endoscopy. Our reviewers says that this code is supported in the records. Our physician reviewer found the operative report states that, "An anterior and posterior ethmoidectomy was completed up to the fovea superiorly and the lamina laterally, protecting any violation of the orbit or the CNS." Ultimately, a probe was passed up into the frontal sinus and the frontal sinus opened from below using angulated telescope and cutting instrumentation along with the microdebrider. The polypoid tissue in the frontal sinus was evacuated and the sinus could be visualized from below." After careful review of Medicare guidelines and CPT guidelines, no documentation was found to support that CPT 31253 and CPT 31259 cannot be billed together. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a sinus endoscopy have been met. Therefore, we decided that the Plan has to pay for a sinus endoscopy (31253) provided on August 31, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient care is medically necessary after the elective surgery. The Plan denied your request. The Plan says inpatient care after this service 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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 76-year-old male who has been approved for a planned right acetabular arthroplasty, with associated CPT code 27130. His provider has requested an inpatient admission for the procedure. The review indicates that the enrollee underwent a preoperative assessment on June 7, 2021 from the Internal Medicine Specialist who noted the patient is at low risk for the planned surgery. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The review has determined that the record does show that at the time of inpatient admission the admitting physician reasonably expects that the patient's necessary hospital 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 not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF services. You say that the enrollee is not safe to return home. The Plan denied your request. The Plan says the enrollee does not require daily skilled nursing or therapy services on an inpatient basis.
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 physician reviewer found that the enrollee is at a moderate assist level with transfers, standby assist for walking using a four wheeled walker, and contact guard assist for tall steps. The enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of his 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 enrollee has acute chronic respiratory
failure and needs assistance. The Plan denied your request. The Plan says there is not an expectation that the
enrollee will improve at the 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 physician
reviewer found that the enrollee suffered a brain injury. The enrollee is receiving appropriate care at the present
acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital
where he is currently receiving care. There are no services available at the LTACH that he requires that are not
available at the health care setting being offered by the health plan. Therefore, the requested LTACH services
are not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xifaxan for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Xifaxan for the enrollee.

Benefits for this drug 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on October 29, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status, this claim should be submitted to Original Medicare.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on October 29, 2020.