Persius/hicric huggingface dataset:
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 really need physical therapy so you can get better and go home. 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for sepsis, a urinary tract infection and a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do 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 you 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on March 12, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. 
The Plan denied your request. The Plan says that the service is not payable as it was rendered by an out of network 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 pay for care from in-network and out-of-network providers. 

The provider in this case is not a network provider with the Plan. However, the Plan contract states that you can receive your care from either a network provider or an out-of-network provider. Additionally, you do not need to get a referral or prior authorization to receive care from out-of-network providers. Therefore, we decided that the Plan has to pay for the annual wellness visit (G0439) rendered by the out-of-network (OON) provider on March 12, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a contact lens fitting, and contact lenses (92310, V2599) provided on January 12, 2021.

You asked the Plan to pay for contact lenses and fitting. You say that in the past years, the Plan has covered your contact lenses. The Plan denied your request. The Plan says you received your vision services within the two-year plan benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers contact lenses once every 2 years (instead of lenses and frames). 

The services you asked the Plan to pay for are considered routine vision services or eyewear. The record shows that the Plan covered contact lenses for you on January 9, 2020. This means that you have exhausted the Plan's benefit for contact lenses and were not eligible for another pair on January 12, 2021. Therefore, we decided that the Plan does not have to pay for a contact lens fitting, and contact lenses (92310, V2599) provided on January 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (PT) services provided in the home setting on May 15, 2020.
You asked the Plan to pay for the home PT services. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says there is a more appropriate code to report these services.
The Plan must follow Medicare rules. Medicare rules say that therapy services provided and billed incident to the services of a physician or NPP must be provided under direct supervision of the billing physician. In this case, the services were provided by a physical therapist in the home but are billed by an NPP. There is no evidence to suggest that this NPP was present in the home to provide direct supervision. As such, these therapy services cannot be billed by this NPP. Therefore, we decided that the Plan does not have to pay for the physical therapy (PT) services provided in the home setting on May 15, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Privigen.

You asked the Plan to pre-approve Privigen. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Intravenous Immunoglobulin is only covered for certain indications. 

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 Privigen. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found it is unclear how the diagnosis of a myopathy was reached in this case. In addition, there is no evidence in the literature that Intravenous immunoglobulin (IVIG) is safe and or effective for "COVID induced myopathy". There is otherwise a lack of literature to support that the clinical information provided otherwise supports the use of IVIG in this setting. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met. Therefore, we decided that the Plan does not have to pre-approve Privigen.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), the alveoloplasty in conjunction with extractions (D7310 x2) and the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x10) received March 9, 2021 from the Medicare opt-out provider.

You asked the Plan to pay for the dental services. You say that you needed these extractions for health reasons to prepare for dentures and to prevent heart issues. The Plan denied your request. The Plan says services provided by Medicare opt-out providers are only covered when receiving Emergency care or Urgent care services.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when they are received from a provider who has opted out of Medicare. The Plan has submitted evidence that the provider in this case has opted out of Original Medicare and does not accept payment from Medicare. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), the alveoloplasty in conjunction with extractions (D7310 x2) and the extractions, erupted tooth or exposed root (elevation and/or forceps removal) (D7140 x10) received March 9, 2021 from the Medicare opt-out provider.
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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on July 9, 2021 after a golf cart accident. She suffered an abdominal wall hematoma and traumatic brain injury. The enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The documentation does not support that the requested LTACH services are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on June 29, 2020.

You asked the Plan to pay for the laboratory test. You say that payment in full is required for clinical laboratory testing used to diagnose COVID. You say that failure to make payment is in violation of the mentioned laws and you demand all amount dues to be paid in full. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

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 the laboratory test provided on June 29, 2020.

Your complaint about wrongful conduct is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 a LTACH transfer is medically necessary. The Plan denied your request. The Plan says that the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.
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 is currently receiving care. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyaluronan or derivative, gel-one, for intra-articular injection, per dose (CPT code J7326), for the enrollee.

You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee has the appropriate diagnosis but there is no documented conservative care other than a corticosteroid injection in the right knee. The Plan states the enrollee has not tried and failed a comprehensive conservative treatment protocol as required by cited guidelines.

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 injection. Our physician reviewer found the medical records provided do not meet the requires listed in the LCD for Medicare coverage. While x-rays are noted on provider's exam, the actual reports (with radiologist's interpretations) were not provided. Furthermore, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures prior to injection. The documentation does not support failure of at least three months of conservative therapy. Conservative therapy is defined as: 

1. Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, physical therapy if indicated); and 
2. If not contraindicated, simple analgesic and (e.g., acetaminophen) or NSAIDs per hyaluronan product prescribing information. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for viscosupplementation injection in the right knee is not medically reasonable or 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyaluronan or derivative, gel-one, for intra-articular injection, per dose (CPT code J7326), 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 the enrollee is below baseline function, demonstrates ability to tolerate at least 3 hours of therapy daily. The Plan denied your request. The Plan says based on the enrollee's current needs, care is suggested at a skilled nursing facility.
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. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Cologuard test.

You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says the requirement is that you are between 50-85 years old.

The Plan must follow Medicare rules. Medicare rules say that the Cologuard test is covered for enrollees between 50-85 years old. 

You are 92 years old. You do not qualify for this testing. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Cologuard test.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the bone marrow aspiration (CPT code 20939), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee has been recommended to undergo a C3-T1 anterior diskectomy and fusion for multi-level degenerative disk disease with severe foraminal stenosis. The Plan denied your request. 

The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature.

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 the service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. Overall, there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for bone marrow aspirate in the setting of spinal fusion surgery is not medically reasonable or 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the bone marrow aspiration (CPT code 20939), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory pathogen testing provided on May 16, 2020.

You asked the Plan to pay for the respiratory pathogen testing. You say that this should be paid. The Plan denied your request. The Plan says an invalid POS code was reported for these tests.

The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. 

We looked at the file and Medicare rules. The records show that the sample was taken on May 16, 2020 and was not received by the lab until May 18, 2020. As such, the POS code of 81 is not supported. Based on this information, we decided that Medicare rules for coverage of the respiratory pathogen testing have not been met. Therefore, we decided that the Plan does not have to pay for the respiratory pathogen testing provided on May 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a skilled nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 the surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.