Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Cxbladdertesting provided on February 26, 2020.You asked the Plan to pay forCxbladder testing. You say that you disagree with the Plan's decision to deny payment.The Plan denied your request. The Plan says that the denial of payment for this service iscorrect, because this testing is not a covered benefit for the diagnosis listed and was performed for screening purposes.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.This testing was ordered by an in-network provider. The file does not show that the plan provided notice that Cxbladder testing wouldnot be covered. Under Medicare rules, this means Cxbladder testing is considered approved by the plan.Therefore, we decided that the Plan has to pay forCxbladder testing provided on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Guardant360 testing rendered on March 27, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that the Guardant360 panel must be billed with procedure code 81479.The file shows that the Guardant360 panel was not billed with code 81479 but as a panel of codes. Based on this information, we decided that Medicare rules for coverage of these services have notbeen met.Therefore, we decided that the Plan does not have to pay forthe Guardant360 testing rendered on March 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the extremity study rendered on February 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 procedure code 93922 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 93923 and 93922. Code 93922 is a column II code with a modifier indicator of 1 when billed with column I code 93923. Code 93922 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay for the extremity study rendered on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysa continued hospital stay is needed until the enrollee is better.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessaryas 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 careis 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 femur fracture. He required blood transfusion for anemia and required treatment in the ICU for delirium tremens. All chronic medical problems are now stable. There are no complex nursing medical 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.Although there is a documented need for physical therapy services, there is no documentation of a need for intensive rehabilitation therapy. 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 chiropractic care visits to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve 10 chiropractic care visits to be provided by an OON provider. 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 care. 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-approve
10 chiropractic care visits to be provided by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on December 13, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.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 has network providers available who can provide the services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on December 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7285) provided on January 27, 2020.
You asked the Plan to pay for the incisional biopsy of oral tissue. The Plan denied your request. The Plan says this service is not covered under the Plan.
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. Therefore, we decided that the Plan does not have to pay for the incisional biopsy of oral tissue (D7285) provided on January 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on December 23, 2019.
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 procedure code G0483 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing rendered on December 23, 2019.
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 IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation provided indicates there is no reasonable expectation that the patient would 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 pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admission is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a different 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 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the member would be able to fully benefit and/or participate in an IRF level of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approve Prolia. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care 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 Prolia. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the documentation does not support a history a trial of an oral bisphosphonate or zoledronic acid Step therapy, as outlined by the plan, requires a trial of these medications or documentation of a contraindication this documentation. Without the support of the documentation, Prolia is not approved as step criteria is not met.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 12, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says under the Evidence of Coverage, covered out-of-network services are those received for any of the following: emergency services, unforeseen out-of-geographic-service-area urgently needed services, routine travel dialysis, or services the plan has prior-authorized.
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 physician's services. 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 physician's services provided on February 12, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation mileage to your cardiologist's office.
You asked the Plan to pre-approve the additional mileage. You say that you need to have three miles added to you transportation benefit. The Plan denied your request. The Plan says your routine transportation benefit is limited to 50 miles.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when the destination is within 50 miles of the pickup location. There is no provision of the contract that would require the Plan to extend the mileage limit on this benefit. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation mileage to your cardiologist's office.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has chronic back pain and has completed 12 physical therapy visits as of July 14, 2020. Treatments have included soft tissue mobilization, modalities, strengthening, and a home exercise program. The requested therapy is generally accepted as specific and effective therapy for the enrollee's condition; however, there is no indication that the prior physical therapy has provided sustained relief. There is no indication that the enrollee's residual deficits could not be addressed via the home exercise program. The requested physical therapy is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injection.You asked the Plan to pre-approve Euflexxa injection. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan follows Medicare rules. Medicare rules say that Euflexxa injections are 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 Euflexxa injection. Our reviewer says that the documentation does not support that the requested Euflexxa injection is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of osteoarthritis of the knees. The member ambulates with a cane but does not wish to have any surgical intervention. The enrollee takes Tramadol, and also has undergone cortisone injections. The enrollee's last series of Euflexxa injections were 12/04/2019 but this only resulted in mild improvement. There was no information provided documenting the enrollee's functional capacity improved with the injections. There was no information provided indicating that functional capacity improved with the injections. Therefore, the enrollee does not meet criteria for the requested series of Euflexxa injections.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa injection have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission 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 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 the enrollee required moderate assistance with walking a few feet with a rolling walker. The enrollee required moderate and maximum assistance for transfers and activities of daily living. The documentation does not support that the enrollee required an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy, but does not require an intensive rehabilitation therapy program. The enrollee's care needs can be met at a lower level of care.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for PET (78815 26 PI) provided on December 30, 2019.
You asked the Plan to pay for the PET. You say that you would like reconsideration because this service was
billed correctly. The Plan denied your request. The Plan says the diagnosis code billed is not appropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
We find that CPT code 78815 26 PI is not supported in the record. Specifically, per the Medicare Claims
Processing Manual, Chapter 13, 60.16, diagnosis code C18.9 is not an appropriate diagnosis code for the CPT
code billed. Based on this information, we decided that Medicare rules for coverage of the PET have not been
met. Therefore, we decided that the Plan does not have to pay for PET (78815 26 PI) provided on December
30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient transfer.
You asked the Plan to pre-approve acute inpatient transfer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 acute inpatient transfer. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that you require services at another acute care hospital that are not available at the acute care hospital where you are currently receiving care. There are no required medical services identified that are available at the other acute care hospital, that are not available at the current acute care hospital. Consequently, transfer to another acute care hospital is not medically necessary, reasonable, and appropriate for your diagnosis and condition 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 acute inpatient transfer have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient transfer.