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

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an OON PET scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is available in-network.
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 provider at issue in this case is not a network provider with the Plan. 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 an OON PET scan. Our reviewer says that use of the requested out-of-network provider is not medically necessary. Our physician reviewer found PET services are available within network and there is no rationale provided to justify out-of-network 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 an OON PET scan have not been met. 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 an OON PET scan. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional 10 extractions (D7210 x10) provided on January 13, 2021.

You asked the Plan to pay for the extractions. You say that you believe these extractions should be covered. The Plan denied your request. The Plan says the limit of how often this service can be provided has already been reached.

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, you are limited to 3 extractions (D7210) every calendar year. The record shows that you received 13 extractions (D7210) on January 13, 2021, 3 of which were covered by the Plan, and your extractions (D7210) benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the additional 10 extractions (D7210 x10) provided on January 13, 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 are not able to walk on your own and need to regain strength. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.
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 you do not require the intensity of services provided in an IRF. Specifically, you are not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. Your care needs can bet met at a lower level of such as skilled nursing facility or sub-acute rehabilitation. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee's needs cannot be met at a lower level of care. The Plan denied your request. The Plan says the enrollee must complete his full hospital treatment.
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 based on the medical records provided, the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the patient does require physical therapy and occupational therapy, the patient does not require an intensive inpatient rehabilitation therapy 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an injection (96373) provided November 20, 2020.

You asked the Plan to pay for the injection. You say that this service was medically necessary. The Plan denied your request. The Plan says the service was performed by facility staff and only the facility is eligible for payment.

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 code 96373 is not supported in the medical record. Specifically, the enrollee was an inpatient at the time this service was rendered. Only the facility is eligible for payment for this service. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection (96373) provided November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the interstitial continuous glucose monitoring system sensors and transmitter provided from December 11, 2020, to January 10, 2021.
You asked the Plan to pay for the interstitial continuous glucose monitoring system sensors and transmitter. You say that you want an enrollee responsibility outcome. The Plan denied your request. The Plan says this is considered to be a non-therapeutic CGM device per Medicare guidelines and is therefore non-covered.
The Plan must follow Medicare rules. Medicare rules say that this code is not used to bill for supplies used with a covered therapeutic continuous glucose monitor. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitoring system sensors and transmitter have not been met.
Therefore, we decided that the Plan does not have to pay for the interstitial continuous glucose monitoring system sensors and transmitter provided from December 11, 2020, to January 10, 2021.
For retrospective appeals, a non-contract provider is required to submit a valid Waiver of Liability statement indicating the provider will not request payment from the enrollee in the event that the appeal decision is unfavorable. Please remember that you signed a Waiver of Liability in which you agreed not to bill the enrollee for these services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computerized tomography (CT) scan provided on December 28, 2020.
You asked the Plan to pay for the CT scan. 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. In this case, the CPT Code Manual definition of code 74176 is computed tomography, abdomen and pelvis; without contrast material. We find that CPT code 74176 is not supported in the medical record. Specifically, this claim was billed with place of service 22 (outpatient); however, the documentation shows that the enrollee was inpatient during this date of service. This means that this claim was billed with an inappropriate date of service. 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 pay for the computerized tomography (CT) scan provided on December 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT 92511 for Nasopharyngoscopy with endoscope (separate procedure) billed to the enrollee for date of service February 5, 2019.

You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria were not met. The Qualified Independent Contractor (QIC) overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.

Our Medical Director looked at the case file and the reopen request. At issue is whether the medical records support that CPT 92511 for Nasopharyngoscopy with endoscope (separate procedure) was rendered in this case. The QIC Physician Reviewer determined that it is documented that diagnostic nasal endoscopy was performed to provide a more detailed examination of the nasal cavities. The nasal septum, sphenoethmoidal recess, inferior meatus, middle meatus, superior meatus and high nasal fossa were examined. The records in the case file supports that nasopharyngoscopy was performed on February 5, 2019. The Plan requested a reopen and argues that nasopharyngoscopy is defined as an evaluation of the nose and continues to the pharynx. Per the medical records received, the endoscope examination was only performed in the nasal area. The plan notes that nasal endoscopy is performed for diagnostic evaluation of the nose. 

The Plan is correct in this case. CPT code 92511 is defined diagnostic nasopharyngoscopy with an endoscope, which views the surface area extending from the posterior edge of the soft palate to the nasopharyngeal wall, including the Eustachian tube openings. In this case, the operative note does not indicate that that pharynx was visualized. The elements of the coverage rule are not satisfied, and the Medicare billing criteria are 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 this claim have not been met. Therefore, we decided that the Plan does not have to pay for CPT 92511 for Nasopharyngoscopy with endoscope (separate procedure) billed to the enrollee for date of service February 5, 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 enrollee needs 3 hours of exercise. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings.
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 there are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this 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 inpatient rehabilitation facility (IRF) admission and services.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 7, 2021 with a hip fracture and underwent surgical repair on May 8, 2021. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require, or to be able to currently tolerate, 15 hours per week of rehabilitative services with regular physician evaluation. 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-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee's medical needs are being met in the current acute setting.

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 physician reviewer found that the enrollee was in the acute hospital for a non-healing ulcer, and a lower extremity deep vein thrombosis. The enrollee is stable. He has not required prolonged mechanical ventilation. He is receiving appropriate care at the present acute care hospital. He 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. Therefore, the requested LTACH 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluid flow stem cell treatment.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says knee arthritis is not covered for stem cell treatment.
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 requested services. Our physician
reviewer found that you have bilateral osteoarthritis of the knees. You have been given knee braces. The
request is for injection of a viscosupplement and amniotic stem cells. This is an experimental/investigational
treatment for osteoarthritis. Therefore, the request is considered not medically necessary or reasonable.
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 fluid flow stem cell treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the limited oral evaluation - problem focused (D0140) provided November 19, 2020 from an out-of-network provider.
You asked the Plan to pay for the dental services (D0330, D0140). You say that the enrollee was referred by their primary care physician to the out-of-network provider. The Plan denied your request. The Plan says there is no coverage when services are rendered by an out-of-network provider.
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. The Plan contract states that there is no coverage when services are rendered by an out-of-network provider. In addition, there are network providers available in the Plan's service area. Therefore, we decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the limited oral evaluation - problem focused (D0140) provided November 19, 2020 from an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says rules for the continuation of SNF care have not been met.
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 continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is an 88-year-old female with a past medical history of hypertension, diabetes, hypothyroidism and cognitive decline who has been in a skilled nursing facility since April 9, 2021, after a fall in her home. Her last covered day in the SNF was May 7, 2021. Based on the medical records provided there is no documentation that the patient requires skilled nursing services or skilled therapy services on a daily basis. This patient does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate 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 continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care.
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 these services. You say that the enrollee needs help with therapy. The Plan denied your request. The Plan says the 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee presented to the hospital on April 14, 2021 with an unresponsive episode with hypoglycemia. He was treated in the hospital with intravenous antibiotics for a urinary tract infection and adjustment of his diabetes medications and debridement of the foot wound and improved. He was weak and de-conditioned and was working with physical and occupational therapy. He was not ambulatory and was dependent for transfers (Hoyer lift) and minimum to moderate assist for upper body activities of daily living (ADLs) and maximum assist for lower body ADLs which were unchanged from his recent baseline level. He has no skilled nursing or skilled therapy needs. He does not require skilled nursing or skilled therapy on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.