Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fasenra.
You asked the Plan to pre-approve Fasenra. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Fasenra. Our reviewer says that the
documentation does not support that the requested drug is medically reasonable or necessary. Our physician
reviewer found the enrollee has asthma. Currently the enrollee is receiving Duoneb, Spiriva, Theophylline,
Ventolin, prednisone, levalbuterol, zileuton, Symbicort per notes. In this case, there is no specific clinical
rationale for the requested medication, Fasenra. While the enrollee does have esosinophilic asthma, the chart
notes do not address this. 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 Fasenra have not been met. Therefore, we decided that the Plan does not have to
pre-approve Fasenra.
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. The Plan denied your request. The Plan says SNF admission 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

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. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 16, 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 the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal.
The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on March 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient therapies provided on February 8, 2021.

You asked the Plan to pay for the outpatient therapies. The Plan denied your request. The Plan says the health Plan requires utilization of network providers when possible and available and requires authorization for certain services. No 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 outpatient therapies provided on February 8, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (78803) provided December 30, 2020.

You asked the Plan to pay for radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowable amount.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 78803 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (78803) provided December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the removal of the basivertebral nerve.
You asked the Plan to pre-approve the removal of the basivertebral nerve. You say that the requested procedure is medically necessary, and the denial is unwarranted. The Plan denied your request. The Plan says the records do not show type 1 or type 2 modic changes on the magnetic resonance imaging. The Plan says that the requested service is not medically necessary.
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 removal of the basivertebral nerve. Our reviewer says that the removal of the basivertebral nerve is not considered medically reasonable and necessary in this case. Our physician reviewer found the removal of the basivertebral nerve and radiofrequency ablation (RFA) of the basivertibral nerve is experimental for low back pain. Our physician reviewer found that more research is needed to show safety and efficacy of the procedure.
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 removal of the basivertebral nerve have not been met. Therefore, we decided that the Plan does not have to pre-approve the removal of the basivertebral nerve.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay for the flu shot the office visit. We decided that the Plan does not have to pay for the office visit.
You asked the Plan to pay for the flu shot the office visit. You say that you have been sick and cannot afford to pay this bill. The Plan says that the provider was out-of-network and the services were not urgent or emergent.
We decided that the Plan has to pay for the flu shot.
The rules say that there are certain services that can be received without getting approval in advance from your primary care physician (PCP). This includes flu shots. The record shows a flu shot was administered. Therefore, we decided that the Plan has to pay for the flu shot .
We also decided that the Plan does not have to pay for the office visit.
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 flu shots, hepatitis B vaccinations, pneumonia vaccinations 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 office visit. We found no exception that would require the Plan to pay for the office visit. Therefore, we decided that the Plan does not have to pay for the office visit provided on October 29, 2020 by an out-of-network (OON) provider.
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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is ready for the next level of care. The appellant says that the medical records provided support the need for care in an IRF. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met.
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 below the knee amputation. The enrollee's medical problems 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. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient stay provided from August 10, 2019, through
August 16, 2019.

You asked the Plan to pay for the inpatient stay. The Plan denied your request. The Plan says authorization was
not obtained.

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 inpatient stay provided from August 10, 2019, through
August 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 11, 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 an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography services coded 77063 and
77067 provided on March 18, 2021.
You asked the Plan to pay for the screening mammography services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 find that CPT codes 77063 and 77067 are not supported in the medical record. Specifically, the services
were billed with an improper taxonomy code. Based on this information, we decided that Medicare rules for
coverage of the screening mammography services have not been met.
Therefore, we decided that the Plan does not have to pay for the screening mammography services coded
77063 and 77067 provided on March 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide a spinal surgery with spacer implantation.

You asked the Plan to provide bilateral lumbar laminectomy, facetectomy and foraminotomy (63047) with insertion of interlaminar/interspinous process stabilization/distraction device (22867). You say that the enrollee would benefit from stabilization with a Coflex device. The Plan denied your request. The Plan says the Coflex implant is 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 provide bilateral lumbar laminectomy, facetectomy and foraminotomy (63047) with insertion of interlaminar/interspinous process stabilization/distraction device (22867). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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 Coflex device placement at L4-5 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 bilateral lumbar laminectomy, facetectomy and foraminotomy (63047) with insertion of interlaminar/interspinous process stabilization/distraction device (22867) have not been met. Therefore, we decided that the Plan does not have to provide a spinal surgery with spacer implantation.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH hospital. 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. 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.

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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visits for hemodialysis provided from January 2021, to March 29, 2021.
You asked the Plan to pay for the home visits for hemodialysis (99512). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the provider is not Medicare certified and is ineligible for payment.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the home visits for hemodialysis provided from January 2021, to March 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the second colonoscopy provided on April 27, 2021.

You asked the Plan to pay for the second colonoscopy (G0105). You say that the second test was needed because the first one was not readable. The Plan denied your request. The Plan says your benefit maximum for this time period has been reached.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, the second colonoscopy (G0105) exceeds the benefit limit of one screening every 24 months. Therefore, we decided that the Plan does not have to pay for the second colonoscopy provided on April 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 screening testing provided on February 3, 2021.

You asked the Plan to pay for screening testing. You say that it was a requirement of Massachusetts to have this test in order to be let back into the state, and if you did not have it then you would not have been permitted back. The Plan denied your request.
The Plan says the denial of payment for this test is correct, because this test was performed for travel purposes and was provided by an out-of-network provider.

The Plan must follow Medicare rules. Medicare rules say that routine services required by third parties such as government agencies are not covered by Medicare. 

We looked at the file and Medicare rules. This test was performed for routine travel purposes. You say that this testing was required by the government of the Commonwealth of Massachusetts. Based on this information, we decided that Medicare rules for coverage of screening testing have not been met.

Therefore, we decided that the Plan does not have to pay for COVID-19 screening testing provided on February 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service 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 the enrollee is medically stable and does not require daily skilled nursing 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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 thoracic aortic aneurysm repair and aortic valve replacement. Medical problems 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, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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.