Persius/hicric huggingface dataset:
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. You say that the enrollee requires intensive therapies to optimize mobility and strength. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary team approach for rehabilitation care.

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 physician reviewer found that the enrollee was evaluated in the emergency room for dizziness, weakness, and pain. She was discharged home with home health physical therapy services. Her medical problems are stable. The complexity of her nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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.
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 need inpatient rehabilitation services to recover
fully and return to your prior level of function as quickly as possible. The Plan denied your request. The Plan
says the criteria for an IRF are not met. You can safely receive the services you need in another setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve 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 therapeutic, prophylactic, or diagnostic injection represented by code 96372 and the additional supplies represented by code 99072 provided on November 24, 2020.

You asked the Plan to pay for codes 96372 and 99072. 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. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 96372 is Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. We find that CPT code 96372 is not supported in the medical record. Specifically, there were no medical records provided to verify the services billed.

Furthermore, code 99072 has a status code of "B" under the Medicare Physicians Fee Schedule Database (MPFSDB) and no separate payment is made for this code under the fee schedule as payment is bundled into the payment for the services to which this code is incident to. Based on this information, we decided that Medicare rules for coverage of codes 96372 and 99072 have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection represented by code 96372 and the additional supplies represented by code 99072 provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99309) provided April 15, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
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 99309 is not supported in the medical record. Specifically, the claim was billed with the SA modifier. CPT codes billed with the SA modifier are not payable under Medicare. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (99309) provided April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medial branch blocks.
You asked the Plan to pre-approve medial branch blocks. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that medial branch blocks are only covered for certain
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 medial branch blocks. Our reviewer
says that the documentation does not support that the requested services are medically reasonable or necessary.
Our physician reviewer found the enrollee has a history of low back pain and left hip pain with diagnoses of
L3-L4 facet arthritis, lumbar spondylosis, failed back surgery syndrome and status post L4-S1 fusion. The
enrollee has been treated with medical therapy including opiates. The enrollee underwent bilateral L2 and L3
medial branch blocks (MBBs) on May 20, 2021, which provided 80% relief. In this case, there is no
documentation of objective findings on physical examination suggestive of facet mediated pain such as, tender
facet joints, pain with lumbar extension, and positive lumbar axial/facet loading. In addition, there is no
documented failure to respond to non-invasive conservative management such as physical therapy. Therefore,
the enrollee does not meet criteria for the requested 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 medial branch blocks have not been met. Therefore, we decided that the Plan
does not have to pre-approve medial branch blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that this request is medically
necessary. The Plan denied your request. The Plan says this item is statutorily non-covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is statutorily noncovered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not
have to pre-approve a power seat elevation feature (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the astigmatism correcting function provided on March 9, 2021.

You asked the Plan to pay for the astigmatism correcting function. You say that this was a prescription lens that was used for the laser surgery procedure. You say that you are appealing the non-payment of the lens. The Plan denied your request. The Plan says an astigmatism correcting intraocular lens is not covered by Medicare or your benefit plan.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The Plan contract does not list the astigmatism correcting function as a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the astigmatism correcting function have not been met. Therefore, we decided that the Plan does not have to pay for the astigmatism correcting function provided on March 9, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS non-emergency ambulance services (A0428) and
ground mileage (A0425) provided December 5, 2020.
You asked the Plan to pay for the ambulance services. You say that the enrollee was not covered under hospice
on the date of service. The Plan denied your request. The Plan says Original Medicare would be responsible for
payment of all Medicare covered services related or unrelated to the member's terminal condition until the first
day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on December 17, 2020. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the BLS nonemergency
ambulance services (A0428) and ground mileage (A0425) provided December 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance services and mileage provided on February 3, 2021.
You asked the Plan to pay for air ambulance services (A0431) and mileage (A0436). You say that this was an emergent phys9ician ordered air transport for a critically ill patient requiring rapid transport to vascular surgery services. The Plan denied your request. The Plan says the enrollee's medical condition did not warrant air ambulance transport as ground transportation was available.
The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 air ambulance services (A0431) and mileage (A0436). Our reviewer says that the air ambulance services were not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is documentation that the patient suffered from an illness or injury that contraindicated transportation by any means other than ambulance. Based on the medical records provided there is no documentation that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. Medical notes from the treating provider indicate transfer to another medical facility could take place by ground or by air with no clear documentation that ground transport was contraindicated. The medical records provided there is documentation that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services (A0431) and mileage (A0436) have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services and mileage provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve facet joint injections. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee did not have greater than 50% pain relief from prior injections as required by Medicare.

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain clinical 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 facet joint injections. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the enrollee has a history of low back pain secondary to spondylosis without myelopathy or radiculopathy. The enrollee has had 2 previous injections which only provided 30% and 25% relief of pain. Therefore, the enrollee has not had at least consisted 50% pain relief for at least 3 months from the prior therapeutic procedure or at least 50% consistent improvement in the ability to perform previously painful movements and activities of daily living.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).

You asked the Plan to pre-approve Euflexxa. The Plan denied your request. The Plan says a recent x-ray of the enrollee's knees is required to determine the therapeutic necessity of the requested viscosupplementation.

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 Euflexxa. Our reviewer says that Euflexxa (J7323) is not medically reasonable and necessary for the enrollee. Our physician reviewer found no records were provided confirming the presence of knee osteoarthritis by radiographic imaging. Our reviewer found that based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Euflexxa (J7323) is safe and effective for the enrollee. No records were provided confirming the presence of knee osteoarthritis by radiographic imaging. Our physician reviewer also found that radiographic studies in the records from February 3, 2017 are reported to show normal knees. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 3, 2021.

You asked the Plan to pay for the laboratory services. You say that this is an independent laboratory that does
not see the patient directly, only specimens are received from the referring physician to test. You say that the
claim is not hospice related and should be reprocessed for payment. 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 services provided on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the remote monitoring services coded 99458, 99454, and 99457 provided on April 2, 2021.

You asked the Plan to pay for the remote monitoring services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.

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 codes 99458, 99454, and 99457 are not supported in the medical record. Specifically, it is not appropriate to bill these codes more than once in a 30-day period. The documentation shows that codes 99454 and 99457 were already submitted, processed, and paid within 30 days of this date of service in question. Code 99458 is an add-on code. Add-on codes are only covered when billed with an appropriate, covered primary service and cannot be paid as a stand-alone code. Based on this information, we decided that Medicare rules for coverage of the remote monitoring services have not been met. Therefore, we decided that the Plan does not have to pay for the remote monitoring services coded 99458, 99454, and 99457 provided on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88237, 88264, 88271, 88275) provided March 9, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that to report a Comprehensive Genomic Profile (CGP) screening service, providers should use CPT code 81479 (used for the entire bundled multi-test panel). 

We looked at the file and Medicare rules. In this case, multiple unbundled CPT codes were billed for the CGP. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (88237, 88264, 88271, 88275) provided March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Continuous positive airway pressure (CPAP) backup
power supply.

You asked the Plan to pre-approve a CPAP backup power supply. You say that you need this in case there is a
power outage or for when traveling and there is not a reliable source of power. The Plan denied your request. 
The Plan says that this item does not fit the definition of durable medical equipment.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a Continuous positive airway pressure (CPAP) backup
power supply.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard (D9944).

You asked the Plan to pre-approve the occlusal guard. You say that the occlusal guard is medically necessary.
The Plan denied your request. The Plan says this service is not covered under your plan. The Plan also says that
you are not enrolled in the Platinum Dental Rider.

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 an
occlusal guard (D9944).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided on June 2, 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 billed are not payable.

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, we have confirmed that code the CT scan has a bundled relationship with code 70450 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan coded 70450 provided on June 2, 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 IRF care is medically necessary to regain maximum function. The Plan denied your request. The Plan says Based on Medicare guidelines, the IRF services you are requesting do not meet the requirements for approval.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.