Persius/hicric huggingface dataset:
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 records provided support the need for IRF care. You say that the enrollee is medically stable and ready for discharge. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for revision of T10-pelvis fusion for scoliosis. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that the 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services provided on December 11, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient hospital services. You say that you were not aware this provider was OON. The Plan denied your request. The Plan says prior authorization was not received for these services rendered by an OON provider.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services provided on December 11, 2020, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on June 19, 2020.

You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because screening services with no relation to a medical diagnosis of disease for health of the patient are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. 

We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order these specific lab services. Without an order, it cannot be determined whether these tests were requested for covered purposes. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on June 19, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on October 22, 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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performe din the home setting and there is a more appropriate code for these services. 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 physical therapy services rendered on October 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from August 19, 2020 to August 24, 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 records do not support the billing of DRG 481 and diagnosis code N39.0.

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 481 and diagnosis code N39.0 (urinary tract infection, site not specified). 

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 these services. Our reviewer says that the records do not support the billing of DRG 481 and diagnosis code N39.0. Our physician reviewer found the enrollee was admitted to the hospital after a fall with a femur fracture. Her urinalysis was positive for nitrates and bacteria and she was treated with IV antibiotics (Ceftriaxone). To validate a diagnosis of urinary tract infection the medical record was examined. There was no documentation of a urine culture with a colony count of greater than 100,000. . There was no documentation of an acute episode of local or systemic symptoms typically associated with cystitis or pyelonephritis. The reviewed documentation made no mention of any urinary signs or symptoms. The review has determined that the records did not support the billing of DRG 481 and diagnosis code N39.0. 

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 the inpatient hospital services rendered from August 19, 2020 to August 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.

You asked the Plan to pre-approve the CT scan. You say that the enrollee has a history of Crohn's ileitis and other comorbid conditions including renal insufficiency, atrial fibrillation, status post cardiac ablation. You say that the enrollee called with complaints of a retracted ileostomy. You say that the enrollee has a large peristomal hernia and prior significant frozen abdomen with a loss of peri bowel scarring and adhesion. You say that the enrollee had all of a sudden noted retraction of the ileostomy and there was concern about the possibility of ischemia versus recurrence of Crohn's ileitis causing this retraction. You say that a CT scan of the abdomen and pelvis is seriously indicated and recommended. The Plan denied your request. The Plan says the notes provided do not explain why the doctor wants the requested test. The Plan says that medical necessity has not been established.

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 criteria for coverage have not been met. Our physician reviewer found the enrollee has a history of Crohn's colitis and proctocolectomy with ileostomy. There are no records provided indicating the medical rationale for obtaining the requested study. The appeal letter provided is not supported by medical record documentation created at the time of the request. The medical necessity and reasonableness, as defined by Medicare rules, is not established by the provided records.

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) 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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the enrollee has rehabilitation needs to improve strength, endurance, ADLs, and mobility as well as medical needs that necessitates the daily medical oversight provided at the facility. The Plan denied your request. The Plan says that there are no ongoing complex medical needs that need/require physician face to face evaluations at least 3 times a week.

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.

The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for an infection of Charcot's joint, sepsis and right below the knee amputation. The enrollee's medical conditions are stable. 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. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01992) provided on June 8, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for anesthesia services. You say that this is a covered service. The Plan denied your request. The Plan says this was 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 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 anesthesia services (01992) provided on June 8, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on September 29, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service 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 97110 is "Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility". 

We asked our coding 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 use of code 97110 is not supported by the records provided. Our coding reviewer found that the medical records document that the service was performed in a home health or hospice service, therefore, code 97110 is not the most appropriate code to be billed for this service. 

We looked at this coder'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 pay for the services (97110) provided on September 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on November 25, 2020.

You asked the Plan to pay for the x-rays. You say that you did not exceed this amount. The Plan denied your
request. The Plan says the service was denied correctly.

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.

We looked at the file and Medicare rules. The records show that you received bitewing x-rays on February 13,
2020. Your plan only covers bitewing x-rays once per plan year. Based on this information, we decided that the
Plan's rules for coverage of x-rays have not been met. Therefore, we decided that the Plan does not have to pay
for the bitewing x-rays provided on November 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 600 additional units of Velcade for the enrollee.

You asked the Plan to pre-approve the additional units. You say that this is medically necessary. The Plan denied your request. The Plan says the plan can approve 960 units for one year.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 additional units. Our reviewer says that the requested additional units are not medically reasonable or necessary. Our physician reviewer found each vial is 35 units. The entire vial must be billed. Dosing four times every three weeks for one year is 68 times. 68 times over 35 units is 2380 units. Thus, it is correct to allow for 960 units. 

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 additional units have not been met. Therefore, we decided that the Plan does not have to pre-approve 600 additional units of Velcade for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories 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 there is no need for multiple power options.

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 the services. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the enrollee would meet the criteria for a basic wheelchair. The requested accessories are not medically necessary as he does have use of his hands and can operate and control the power options using the switches that are included in the basic wheelchair. He does not appear to require the power seat options as he is not at high risk for skin breakdown and does not have to self-catheterize therefore the requested group 3 power wheelchair with accessories is not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).

You asked the Plan to pay for the lumbar-sacral orthosis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the medical records submitted do not support that the equipment was medically reasonable.

The Plan follows Medicare rules. Medicare rules say that the lumbar-sacral orthosis is subject to the criteria listed 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 pay for the lumbar-sacral orthosis. Our reviewer says that the requested orthosis was not medically necessary and reasonable. Our physician reviewer found an appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for a lumbar-sacral orthosis have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is insufficient documentation of an appropriate evaluation of the enrollee and insufficient documentation of a credible physical examination of the back. 

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 lumbar-sacral orthosis have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis (L0650).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the requested LTACH care is a medical
necessity for you. The Plan denied your request. The Plan says rules for LTACH care have not been met
because the requested services are not medically necessary.

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 services are not medically necessary, reasonable, and appropriate for your diagnosis
and condition. Our physician reviewer found that there is no documentation provided necessitating admission
to a LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services
at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are
no services available at the LTACH that you require that are not available at the health care setting being
offered by the Plan.

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 the LTACH services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel (F1Heme)
provided to the enrollee on January 18, 2021.

You asked the Plan to pay for the testing. You say that this is a proven medically necessary covered benefit for comprehensive genomic profile testing for cancer. The Plan denied your request. The Plan says genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as 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 in this case. Our physician reviewer found the records are insufficient to evaluate the necessity of this testing. There is no complete blood count, no marrow testing, and no workup. 

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 a targeted genomic sequence analysis panel (F1Heme) provided to the enrollee on January 18, 2021.