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

We decided that the Plan does not have to pay for a right total knee replacement.

You asked the Plan to pay for the procedure. 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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is noted to have had physical therapy and "shots". These injections were not clarified in the documentation provided, nor is there documentation of when she attended therapy and the number of sessions attended.

Furthermore, imaging studies show only "mild" osteoarthritis seen in the tricompartmental joint spaces. There
are limited large-scale, long-term references showing the safety and efficacy of the requested surgery in this
clinical setting. There is no compelling rationale presented or extenuating circumstances noted to support the
medical necessity of this request as an exception. Therefore, the request for right total knee replacement 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 procedure have not been met. Therefore, we decided that the Plan does not
have to pay for a right total knee replacement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
February 1, 2021, to February 3, 2021.

You asked the Plan to pay for the services. You say that there was valid authorization for the entire length of
stay for the inpatient visit. The Plan denied your request. The Plan says the claim was reprocessed and paid
based on the level supported by the records.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with DRG 177. 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 services. Our reviewer says that the services at issue in this case were not
supported by the medical records. Our physician reviewer found the provider billed DRG 177 (respiratory
infections and inflammations with MCC). The plan paid based on DRG 178 (respiratory infections and
inflammations with CC). The review indicates that the provider billed ICD-10 code E43 (Unspecified severe
protein-calorie malnutrition) as a secondary diagnosis. This was not documented in the medical record. The
diagnosis was mentioned in the medical record, but it was not consistently mentioned and documented. The
appropriate DRG is 178.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for inpatient hospital services provided to the enrollee from February 1, 2021, to February 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high-intensity focused ultrasound for the enrollee.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that a high-intensity focused ultrasound can be covered post radiation therapy following certain guidelines.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found as the enrollee has never had radiation therapy, the requirements have not been 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a high-intensity focused ultrasound for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided on September 11, 2020.

You asked the Plan to pay for the laboratory test. The Plan denied your request. The Plan says Original Medicare is responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory test provided on September 11, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF 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 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program
or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and,
as a practical matter, can be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Budesonide/Formoterol Aer 160-4.5 for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide/Formoterol Aer 160-4.5 for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inogen G5 portable oxygen concentrator.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says the medical information provided does not indicate why the brands available through the plan are not sufficient.

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 concentrator. Our reviewer says that the requested brand is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do not show a need for this specific request. 

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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an Inogen G5 portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 14, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 01230 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 01230 is anesthesia for open procedures involving upper two-thirds of femur; not otherwise specified. 

We find that CPT code 01230 is not supported in the medical record. Specifically, the records do not support the billing of 175 units of this code. The records document only 125 minutes of anesthesia time provided. Based on this information, we decided that Medicare rules for coverage of these services have not been met.

Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on November 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97110, 97116) provided by a PTA on June 25, 2020.

You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says the submitted codes do not appropriately reflect the services rendered by the PTA.

The Plan must follow Medicare rules. Medicare rules say that a physical therapist must supervise PTAs. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the record does not indicate that a physical therapist was present in the member's home while these services were being rendered. The documentation does not show that a physical therapist was supervising the PTA. Therefore, we decided that the Plan does not have to pay for the physical therapy services (97110, 97116) provided by a PTA on June 25, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient detoxification services provided January 4, 2021.
You asked the Plan to pay for the detoxification services. You say that the medical records provided support
the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee was not
enrolled to participate in the Medicare program on the date of service.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for inpatient detoxification services
provided January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services you received on January 20, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says this provider has opted out of Medicare.
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 a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the dental services you received on January 20, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a bone density test provided by a participating provider on March 11, 2021.

You asked the Plan to waive the copayment for a bone density test. You say that you would like to appeal these charges. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $45 copayment for outpatient diagnostic tests/diagnostic tests. 

You have been asked to pay a $45 copayment for a bone density test. Since a diagnostic test was provided, the correct copayment has been applied. A bone density test falls within the outpatient diagnostic tests/diagnostic tests benefit category. 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 a bone density test provided by a participating provider on March 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (CPT code 64625).
You asked the Plan to pre-approve the injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of radiofrequency ablation to the SI joint in the setting of sacroiliitis have not been demonstrated in the peer-reviewed literature.
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 injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy published in the literature. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve RFA, nerves innervating the SI joint, with image guidance (CPT code 64625).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a heavy-duty walker purchased on February 5, 2021.

You asked the Plan to pay for this walker. You say that the Plan should pay for this equipment as it was medically necessary, and you did not know this provider was not a Medicare eligible provider. The Plan denied your request. The Plan says this walker was purchased without prior authorization from a provider who is not a Medicare eligible provider. The Plan says that even if you have purchased the equipment from an eligible provider, prior authorization was still required per your Plan contract agreement.

Medicare rules say that plans can require enrollees to get prior authorization. Medicare rules say that the equipment provided or purchased must be obtained from Medicare eligible providers. The contract with the Plan says that durable medical equipment requires prior authorization and enrollees must use Medicare eligible provider. The provider you purchased this equipment from is not a Medicare eligible provider. You did not have prior authorization for this equipment. Therefore, we decided that the Plan does not have to pay for a heavy-duty walker purchased on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the epidural injection services provided on January 25, 2021.

You asked the Plan to waive the cost shares for the services provided. You say that it was an injection, not an overnight stay. The Plan denied your request. The Plan says the claim processed correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).

The file shows that you received a lumbar epidural injection. This is considered a surgical service. You were charged $283.70 for the service provided. Because the amount is less than the $360 copay, you were charged the lesser amount. The service falls within the outpatient surgery benefit category. You were also charged a 20% coinsurance for the Triamcinolone injected drug. The service falls within the Medicare Part B prescription drugs benefit category.

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 cost shares for the epidural injection services provided on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that LTACH is medically necessary for continued care and the enrollee meets Medicare criteria requirements for placement. The Plan denied your request. The Plan says the enrollee has not completed a full course of care in the hospital and the doctors have recommended inpatient rehabilitation care.

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. Our physician reviewer found there is no documentation provided demonstrating medical necessity for LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she 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. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

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 LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the OmniSeq panel test provided to the enrollee on April 20, 2021.

You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says the requested testing lacks clinical evidence of usefulness.

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 test. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records provided did not clearly describe how performing this test would lead to improved outcomes or a clear productive decision in care. On review, there was insufficient high-quality literature found on the OmniSeq Advance gene testing for this specific clinical situation to support its general use. Therefore, the OmniSeq panel test will be considered not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the OmniSeq panel test provided to the enrollee on April 20, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
You asked the Plan to pre-approve the SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or skilled therapy 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 SNF care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on September 12, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory
services rendered on September 12, 2020.