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

 
We decided that the Plan does not have to pay for the Guardant360 Plasma-Based Comprehensive Genomic 
Profiling testing provided on February 8, 2020 billed with multiple line items of different CPT codes. 
 
You asked the Plan to pay for the Guardant 360 testing as billed. You say that this should not be denied as 
experimental as this is a proven test which is supported for this patient. The Plan denied your request. The Plan 
says on review, it was found that no payment can be made for this testing because the provider is unbundling 
when there is a single CPT code which describes this testing. 
 
The Plan must follow Medicare rules. Medicare rules say that in order to report the Guardant360 testing, one 
unit of code 81479 should be reported with the appropriate DEX Z-code.  
 
As there is a single CPT code which describes this testing, the rule for coverage of this testing as billed have 
not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 Plasma-Based 
Comprehensive Genomic Profiling testing provided on February 8, 2020 billed with multiple line items of 
different CPT codes.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the LifeVest rental for date of service February 2, 2020 billed with 
code K0606-RR-KF-KI-KX. 
 
You asked the Plan to pay for the LifeVest rental. You say that this was correctly billed for the second month's 
rental of this device. The Plan denied your request. The Plan says that the claim was billed with a modifier that 
is inappropriate for this procedure. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has not raised a specific issue with the modifiers appended to the code 
in this case. Modifiers RR and KF are required and listed with the code in the DME Fee Schedule. Modifier KI is used to indicate the second or third month of rental. The Plan did not show that this was not the second or third month of the rental. 
The KX modifier is also required to indicate that coverage criteria are met. The Plan made no specific 
argument to support that the criteria were not met. Without any valid rationale for denial, we find that the 
denial of payment for this item is not substantiated. Therefore, we decided that the Plan has to pay for the 
LifeVest rental for date of service February 2, 2020 billed with code K0606-RR-KF-KI-KX.  
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CPT code 99190 provided on February 25, 2020. 
 
You asked the Plan to pay for CPT code 99190. You say that you would like the Plan to reconsider their denial 
of payment. The Plan denied your request. The Plan says the enrollee received these services in the facility 
during an inpatient hospitalization and payment for these services would be included in the Part A-DRG 
payment to the facility. The plan states payment for these services is the responsibility of the facility. 
 
The Plan must follow Medicare rules. Medicare does not pay any provider or supplier other than the facility or 
hospital for services furnished to the beneficiary while an inpatient.  
 
We looked at the file and Medicare rules. In this case, the file shows the enrollee received these services during 
an inpatient hospitalization. Payment for these services were included in the facility payment. Therefore, we 
decided that the Plan does not have to pay for CPT code 99190 provided on February 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical information did not support the medical necessity for this service.
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 wheelchair. 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 reveal that you have a mobility limitation that significantly impairs your ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal that your mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker or that your home provides adequate access between rooms, maneuvering space, and surfaces for use of a manual wheelchair. You do not meet the criteria for a manual wheelchair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair.
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. The Plan denied your request. The Plan says the enrollee does not need frequent physician visits, 24-hour nursing care, or special equipment.
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 physician reviewer found that you are bed and chair bound mostly, and can barely stand on your own. You do not walk much, but can stand with difficulty on request. The physician's note indicates chronic sacral decubitus ulcer. The physical therapy home health note states you are at total dependence for bed mobility and transfers. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from physical and occupational therapy, but the documentation does not support that your functional status requires an 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet joint intervention. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the 
enrollee has not undergone recent medial branch blocks to ensure the appropriate location of the 
radiofrequency ablation. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under 
certain medical 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 the requested services. Our physician 
reviewer found that the enrollee has low back pain with right lower extremity radiculopathy radiating to the 
right foot, left hip pain and fibromyalgia. The office notes document that the enrollee has lumbar pain which 
radiates down right foot. The enrollee has lower back pain responsive to Rhizotomy 3 years ago. The pain is 
characterized as achy, cramping, dull, shock-like, tingling/pins and needles, shooting, tiring, stabbing, and 
sharp throbbing. The pain is constant, and worse throughout the day and night. The provided medical records 
do not show that the enrollee has satisfied all of the coverage requirements. Therefore, the requested services 
are 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 facet joint intervention.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99153 provided on April 23, 2020.
You asked the Plan to pay for CPT code 99153. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, the review shows that the medical records provided represent professional charges; however, procedure code 99153 was provided in a facility with a place of service code of 23. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for CPT code 99153 provided on April 23, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional level requires an 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper gastrointestinal endoscopy (43239) provided on March 3, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment 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 copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for ambulatory surgery. You have been asked to pay a $200 copayment for the ambulatory surgery 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 copayment for the upper gastrointestinal endoscopy (43239) provided on March 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine
transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you need this transport
for a procedure you are having done. The Plan denied your request. The Plan says that your request exceeds the
benefit limit.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we
decided that the Plan does not have to pre-approve an exception to the 50 mile limit for routine transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve bone marrow aspiration. You say that the enrollee needs this procedure. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because medical studies have not shown that this procedure is helpful for the enrollee's condition.
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 bone marrow aspiration. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure remains experimental for use in spinal fusion surgery. More research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three endosteal implants (D6010 x3).
You asked the Plan to pre-approve the endosteal implants. You say that you are not able to eat. The Plan denied your request. The Plan says this service is not covered under your benefit package.
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 pre-approve three endosteal implants (D6010 x3).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the 
enrollee. 
 
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. 
The Plan denied your request. The Plan says that the enrollee's complex medical needs are being met in the 
current acute setting at this time. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient 
is currently undergoing treatment at an acute care hospital (ACH) for heart failure. The enrollee is not 
intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As 
LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the 
enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are 
required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 
Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 
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 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 for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz viscosupplement injections.
You asked the Plan to pre-approve the Supartz injections. You say that this treatment should be approved. The Plan denied your request. The Plan says there is no medical reason provided that the enrollee cannot use a preferred viscosupplement agent.
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 the Supartz injections. Our reviewer says that the requested injection is not considered reasonable and necessary based on step therapy rules. Our physician reviewer found the patient is a 70-year-old female with diagnosed knee osteoarthritis who had failed conservative treatments and steroid injections. Supartz injections were requested. According to the provided records, the patient has not tried and failed Monovisc or Orthovisc. There was no suggestion from the notes that Monovisc or Orthovisc would be less effective or be less safe than the requested Supartz injections as these medications are considered equivalent in safety and effectiveness based on currently available studies.
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 Supartz injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz viscosupplement injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on January 7, 2020.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provider has opted out of the Medicare program.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the physician services provided on January 7, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care for the enrollee. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically 
necessary. The Plan denied your request. The Plan says that the enrollee's inpatient stay should be included 
with previous stay. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. This hospitalization in question is directly correlated with his recent stay where he left AMA and not 
getting therapy recommended by his providers and is, therefore, a result of the same unresolved problem from 
the recent stay. This does not represent a new problem, but an unresolved very recent issue that he chose not to 
address. It is reasonable that the hospital stay in question be tied to his prior stay. Our physician reviewer found 
that the enrollee's condition does not meet criteria for inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the mental health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the provided services were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 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 the mental health services provided on February 12, 2020 by an out of network (OON) provider.