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

We decided that the Plan does not have to pay for lab services (80307, 99214) provided on [[CASE/@DOS]. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the out-of-network services were not pre-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 had network providers 
available who could have provided the 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 services. Therefore, 
we decided that the Plan does not have to pay for lab services (80307, 99214) provided on [[CASE/@DOS].
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) foot (73700).
You asked the Plan to pre-approve the CT scan. You say that The enrollee needs dual energy CT scan because it will highlight gout crystal, which cannot be seen on MRI. The Plan denied your request. The Plan says the medical records do not show that the request does not meet medical necessity.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has a history of gout that is being treated. The enrollee is also being treated for CML. The records indicate that the physical examination of the feet and ankles is normal. The provided record does not indicate how the requested test would alter treatment. The requested test is not medically necessary and reasonable as defined by Medicare rules. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) foot (73700).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Interfyl injection.
You asked the Plan to pre-approve the requested services. You say that you are in pain. The Plan denied your request. The Plan says the effectiveness of amino injections has not been demonstrated for your condition in the peer-reviewed literature.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 the requested services. Our physician reviewer found that the requested use of the Interfyl is not FDA approved for the enrollee's diagnosis. It is clear in the medical documentation that you are suffering with painful posterior calcaneal bursitis along with Achilles' tendinitis right side. You have undergone numerous conservative treatments but continue to have pain to the posterior right heel. The medical documentation does not support that you are suffering with deficit/inadequate soft tissue, deep dermal and surgical wounds, soft tissue voids, and tunneling wounds. Its use is not supported by a major drug compendium or by clinical research. Interfyl injections are not considered standard of care for retrocalcaneal bursitis. Therefore, the requested injection of Interfyl for your medical condition 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Interfyl injection.
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 IRF admission is medically necessary because you
want to return to being independent. The Plan denied your request. The Plan says under Medicare, the request
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 that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. 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. 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 pay for the laboratory services rendered on February 22, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 22, 2021.
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 you will benefit from an IRF admission. The Plan denied your request. The Plan says criteria for admission to the Acute Inpatient Rehabilitation setting 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.
Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do require physical and/or 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 pay for the multiple laboratory tests provided on July 10, 2020.
You asked the Plan to pay for the lab testing. You say that this should be paid. The Plan denied your request. The Plan says many of these codes are not separately payable due to Column 1/Column 2 edits.
The Plan must follow Medicare rules. Medicare rules say that providers must submit sufficient documentation to support that payment is due and to confirm that Medicare coverage criteria are met. No medical records were submitted to support the medical necessity of this extensive testing. There is no copy of the results nor records from the ordering physician. As such, we find that the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the multiple laboratory tests provided on July 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acute inpatient rehabilitation facility (IRF) services.
You asked the Plan to pre-approve IRF care. You say that you need continuing IRF care and services and want to stay at the current facility. The Plan denied your request. The Plan says you are not showing any functional improvements after 23 days of daily skilled therapy. It does not appear that you require continued physician oversight or an inpatient setting for care. You would be appropriate for a lower level of care at this time.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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 continued acute inpatient rehabilitation facility (IRF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on October 30, 2020.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on October 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on June 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says service providers should use CPT code 81479.
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at
issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing provided to the enrollee on June 17, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on August 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says payment for these services is made in the facility payment.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to these services would have been included under the facility claim. Therefore, we decided that the Plan does not have to pay for the services provided on August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections at three bilateral levels.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says two levels are approved but three levels is not covered.
The Plan must follow Medicare rules. The rules say that one to two levels, either unilateral or bilateral, are
allowed per session per spine region.
We looked at the file and Medicare rules. The requested services are facet injections at three levels. The Plan
has approved two levels. Three levels are not covered by Medicare. Therefore, we decided that the Plan does
not have to pre-approve facet joint injections at three bilateral levels.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee needs this equipment. The Plan denied your request. The Plan says the item is not covered.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the WATS 3D biopsy provided on January 14, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary. Our physician reviewer found that The American Society of Gastrointestinal Endoscopy suggests using WATS-3D (brush) biopsy testing in patients with known or suspected Barrett's esophagus. The available clinical documentation in the case file does not support that the enrollee in this case has known or suspected Barrett's esophagus.
The documentation does not support that the WATS 3D biopsy testing was medically reasonable and necessary for the enrollee in this case. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the WATS 3D biopsy provided on January 14, 2021
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pay for the imaging guidance coded as 77012-26. We decided that the Plan does not have to pay for the additional moderate sedation coded as 99153.
You asked the Plan to pay for the billed services. You say that these services should be paid. The Plan says that 99153 is not payable in the outpatient hospital setting.
We decided that the Plan has to pay for the imaging guidance coded as 77012-26.
The Plan follows Medicare rules. Medicare rules say that the Plan must submit sufficient information to support denials of payment. In this case, the Plan indicated that this code was to be handled as a separate case. However, the Plan did not indicate the outcome of that separate case, nor did the Plan provide a valid reason that the code was exempt from the Medicare appeal process. Per our contract with Medicare, we must render a decision on all codes at issue. Since no valid denial rationale for this code was provided, we find that the denial is not supported. Therefore, we decided that the Plan has to pay for the imaging guidance coded as 77012-26.
We also decided that the Plan does not have to pay for the additional moderate sedation coded as 99153.
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid in the facility setting. The Outpatient Prospective Payment System (OPPS) applies to all hospital outpatient departments. This service was performed in the facility setting, meaning that no separate payment can be made to the physician. Therefore, we decided that the Plan does not have to pay for the additional moderate sedation coded as 99153.
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 requires acute rehabilitation and a denial will jeopardize their chance for a full recovery. The Plan denied your request. The Plan says the criteria are not met for an IRF. The enrollee can safely receive the necessary care in an alternative setting.
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 that 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. 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. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power mobility device.
You asked the Plan to pre-approve these 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 follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 you do not meet the criteria for coverage. Our physician reviewer found the submitted records do not show that you have a personal mobility deficit that impairs participation in mobility-related activities of daily living (MRADLs), such as toileting, feeding, grooming, and bathing. There is no documentation that you cannot use a walker, cane, or manual wheelchair. The records do not show that you can safely operate a power mobility device. The criteria for coverage are not met and the services are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power mobility device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 22, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code. We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple
code. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 22, 2020.