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 the stay is medically necessary. 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 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 gastrointestinal bleeding. Medical conditions 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. 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 patient 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: DME/ Orthotics
Decision: Unfavorable

December 2, 2020, to February 2, 2021, by an out of network provider.

You asked the Plan to pay for an automatic external defibrillator. You say that you were told the requested service had been authorized and that you cannot afford to pay the bill at issue. The Plan denied your request. The Plan says rules for out of network care have 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve out of network provision for the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on December 2, 2020, to February 2, 2021, by an out of network provider.
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 a high fall risk. The Plan denied your request. The Plan says the enrollee is receiving and tolerating adequate rehab in the inpatient rehab facility.

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 has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). He has tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. He could benefit from continued services at the current level of care. There is no indication that transfer to a skilled nursing facility is required. He can continue to receive skilled rehab services at the current IRF. There are no services offered at a SNF that are not offered at an IRF. Therefore, an admission to a SNF for inpatient rehab services is 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for the ambulance transportation service (A0429) provided on December 28, 2020.

You asked the Plan to waive the co-payment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the co-payment has been applied correctly to the service provided.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225 co-payment for each Medicare-covered one-way trip by ground ambulance transportation.

You have been asked to pay a $225 co-payment for the Medicare-covered one-way ground ambulance trip provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co-payment for the ambulance transportation service (A0429) provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided on December 5, 2020 to December 17, 2020 by an out of network provider.

You asked the Plan to pay for dialysis services. You say that the Plan should pay this claim. The Plan denied your request. The Plan says you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services 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 these services. Therefore, we decided that the Plan does not have to pay for dialysis services provided on December 5, 2020 to December 17, 2020 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (80050) provided to the enrollee on November 19, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. 

You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the lab services (80050) provided to the enrollee on November 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on December 1, 2020, by an out of network provider.

You asked the Plan to pay for an automatic external defibrillator. You say that the requested item was a necessity for the enrollee's care. The Plan denied your request. The Plan says rules for out of network care have 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 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an automatic external defibrillator (K0606) provided on December 1, 2020, by an out of network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.

You asked the Plan to pre-approve additional services. You say that you need to strengthen the muscles around the knee. The Plan denied your request. The Plan says the skills of a therapist are not needed.

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 additional services. Our physician reviewer found that you have been receiving physical therapy for knee pain. You also received a steroid injection. The documentation indicates you have full strength and range of motion of the knee. You have been educated regarding a home exercise program. The additional therapy services are not an appropriate duration and frequency for treatment of your condition, and therefore 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (G0453 and
95940) provided on November 25, 2020.

You asked the Plan to pay for intraoperative neurophysiology monitoring. You say that these services should
be covered. The Plan denied your request. The Plan says these codes cannot be paid as 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 G0453 is continuous intraoperative neurophysiology
monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to
one patient) each 15 minutes (list in addition to primary procedure). The definition of 95940 is continuous
intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal
attendance, each 15 minutes (List separately in addition to code for primary procedure).

We find that CPT codes G0453 and 95940 are not supported in the medical record. Specifically, these codes are add-on codes that were not billed with an appropriate primary procedure. Based on this information, we decided that Medicare rules for coverage of intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for intraoperative neurophysiology monitoring (G0453 and 95940) provided on November 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81206, 81210, 81235, 81275,
81276, 81292, 81295, 81298, 81301, 81317, 81401, and 81404 provided on September 18, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not payable.

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 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, and
81404 are not supported in the medical record. Specifically, these services were part of sequencing procedure,
which should be billed with a bundled code rather than separately billed. Based on this information, we decided
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the
Plan does not have to pay for the laboratory services coded 81206, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81301, 81317, 81401, and 81404 provided on September 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 8, 2019.

You asked the Plan to pay for lab services. You say that the untimely filing of this claim was through no fault of your own. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. 

The record shows that a claim for lab services was not filed until February 5, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for laboratory services provided on October 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September
30, 2020.

You asked the Plan to pay for a neuromuscular stimulator. You say that this should be covered. The Plan
denied your request. The Plan says there is not a valid proof of delivery for this item.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.

The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of
delivery in the file shows a shipping and delivery date in March of 2020. The billed date of service for the item
at issue is September 30, 2020. The record shows that the Plan made several attempts to obtain the necessary
documentation without success. Therefore, we decided that the Plan does not have to pay for a neuromuscular stimulator (E0745) provided on September 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI scan of the thoracic spine (72157).

You asked the Plan to pre-approve a spinal MRI. You say that the requested MRI is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for MRIs have not been met.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary.

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 a spinal MRI. Our reviewer says that an MRI is not medically reasonable and necessary. Our physician reviewer found that detailed documentation is not evident in the case record regarding trial and failure of recent, reasonable, and comprehensive less invasive conservative care measures. Detailed documentation is not evident regarding significant worsening of neurological deficits. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of the requested MRI as an exception.

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 spinal MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve an MRI scan of the thoracic spine (72157).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from November 17, 2020, through
December 16, 2020.

You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says based upon Medicare coverage guidelines, medical necessity cannot be established for admission to the skilled nursing facility beginning on November 17, 2020, through and including December 16, 2020.

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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had cognitive impairment. His oral intake was good. Regarding rehabilitation services, the enrollee received a brief course of physical therapy (PT) in the SNF. By the dates in question, the enrollee was at independent with functional mobility including gait to 750 feet. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, this 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from November 17, 2020, through December 16, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Exosome Prostate Intelliscore test for the enrollee.
You asked the Plan to pre-approve the test. You say that this is medically necessary. The Plan denied your request. The Plan says there are currently no listed clinical indications for this test.
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 test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 76 year old male with BPH and a PSA of 6.3 from 2/16/2021 which had risen from 1.4 in 2016. Exosome Prostate Intelliscore test was ordered. There are currently no clinical indications listed for this particular test in the MCG 25th edition guideline. There is limited supportive evidence that this test leads to improved outcomes relative to the standard of care (biopsy) to justify its use in this clinical situation at this time. Therefore, this enrollee does not meet criteria for this test. 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 test have not been met. Therefore, we decided that the Plan does not have to pre-approve the Exosome Prostate Intelliscore test for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on November 24, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.

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 test requisition form indicates that the in-network provider was requesting this testing for non-screening purposes. The file does not show that the plan provided notice that genetic testing would not be covered. Under Medicare rules, this means genetic testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for genetic testing provided on November 24, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the SNF admission. You say that the enrollee would benefit from SNF care. The Plan denied your request. The Plan says the enrollee does not require skilled services on a daily 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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the hospital with a stroke with mild dysarthria, right facial weakness and with a concurrent acute on chronic congestive heart failure exacerbation. He was treated in the hospital with Eliquis, aspirin, a statin and intravenous diuresis and improved. He is weak and deconditioned and is working with physical and occupational therapy as well as speech therapy. He is walking 200 feet with a rolling walker with stand-by assistance/supervision and is stand-by assist/supervision for transfers and is supervision to minimum assist for most activities of daily living. Therapy notes indicate anticipated discharge location is "home with family assistance." He is reported to be medically stable for discharge.

There is no documentation that the patient requires skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. There is documentation of the need for skilled therapy services; however, daily skilled therapy is not medically necessary. based on the medical records provided, this patient does not require the services on an inpatient basis, only 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 the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).