Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve three (3) HH SN visits (CPT code G0299 x3), for the enrollee.  You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee's medical conditions appear stable and there have been no recent changes to their treatment plan or their medications. The Plan states home skilled nursing visits were ordered to teach the enrollee about disease and medication management.   The Plan states the enrollee's previously approved visits should have allowed their nurse to review their medical conditions, medication management, pain management, diet, and household safety with the enrollee. The Plan states the enrollee's records do not support the need for a skilled nurse to make more visits.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 physician reviewer found the health plan's denial should be upheld. The enrollee does not have documented skilled nursing needs (i.e.: IVs, complex wound care, new ostomy). As such, the requested, ongoing, HH SN services are 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve three (3) HH SN visits (CPT code G0299 x3), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.  You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure is helpful for treatment of the health problem.  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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show 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 the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for GeneSight testing (81479) provided on August 5, 2021.  You asked the Plan to pay for GeneSight testing. You say that this is a covered service. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that in order for Pharmacogenomics Testing services to be covered, the patient's medical record must clearly reflect that the criteria listed in the rules section have been met.  We looked at the file and Medicare rules. The submitted medical records do not include records from the ordering provider demonstrating that the criteria for coverage have been met and that the testing at issue was medically necessary. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Based on this information, we decided that Medicare rules for coverage of GeneSight testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight testing (81479) provided on August 5, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for X-rays of the hip and spine provided on August 10, 2021.  You asked the Plan to waive the copayments for the X-rays. You say that you feel that only one copayment should apply for both sets of X-rays. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $15 copayment for each X-ray service.   The record shows you had two sets of images done, one each for the spine and hip.   Therefore, you have been asked to pay $30 for the X-rays ($15 copayment x 2 image sets). the X-rays falls within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies 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 copayments for X-rays of the hip and spine provided on August 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the 5 services performed by a qualified occupational therapist (G0152) provided from May 18, 2021, to June 9, 2021.  You asked the Plan to pay for the occupational therapy services. You say that the combined efforts of physical therapy and occupational therapy were necessary to improve safe mobility with proper energy conservation, bilateral upper and lower extremities strength, cognitive task applications, and dynamic balance to prevent falls, to increase independence and improve quality of life. The Plan denied your request. The Plan says the request for occupational therapy visits does not meet medical necessity criteria.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 performed by a qualified occupational therapist. Our reviewer says that ongoing home health occupational therapy services were medically necessary and reasonable. Our physician reviewer found the occupational therapy records do not clearly show that the enrollee was making progress with home health occupational 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 services performed by a qualified occupational therapist have not been met. Therefore, we decided that the Plan does not have to pay for the 5 services performed by a qualified occupational therapist (G0152) provided from May 18, 2021, to June 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the complete bilateral noninvasive physiologic studies (93923), and duplex scan of lower extremity arteries or arterial bypass grafts (93925), provided on August 6, 2021.  You asked the Plan to waive the copayment for the complete bilateral noninvasive physiologic studies and duplex scan of lower extremity arteries or arterial bypass grafts. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share was applied 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). Your contract with the Plan clearly says that you must pay a $25 copayment for outpatient diagnostic tests and therapeutic services and supplies.    You have been asked to pay a $25 copayment for the complete bilateral noninvasive physiologic studies and duplex scan of lower extremity arteries or arterial bypass grafts. These services fall within the outpatient diagnostic tests and therapeutic services and supplies 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 the complete bilateral noninvasive physiologic studies (93923), and duplex scan of lower extremity arteries or arterial bypass grafts (93925), provided on August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for specialist office visits provided from August 10, 2021, to August 12, 2021.  You asked the Plan to waive the copayments for the specialist office visits. You say that you cannot afford these copayments. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  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 $40 copayment for each specialist visit.     You have been asked to pay a $40 copayment for the specialist office visit provided on August 10, 2021. You have also been asked to pay $26.61, which is less than the $40 copayment for the specialist office visit provided on August 12, 2021. The total for the two visits is $66.61. The specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 copayments for specialist office visits provided from August 10, 2021, to August 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the echocardiography rendered on August 17, 2021.  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 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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the echocardiography rendered on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight testing rendered on August 23, 2021.  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 there is no valid physician order.  The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.      We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight testing rendered on August 23, 2021.
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 recommendation from your doctor is that you go to the rehabilitation facility. You state you are not safe at home because you are alone and do not have anyone to assist or care for you at home. The Plan denied your request. The Plan says your records show that you do not need to be seen by a rehabilitation doctor at least three (3) times a week for evaluation of functional and medical goals and progress. The Plan states your records also show that you do not need an intensive team (rehabilitation doctor and nurse, social worker, and therapists) to oversee your care. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health services or home with outpatient therapy.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you are stable with no acute medical illness and does not meet Centers for Medicare & Medicaid Services (CMS) coverage criteria for an IRF admission. With your current medical stability, and no other acute medical complexity, there is no need for Physical Medicine and Rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs noted in the record. At the current functional level, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy. Your therapy needs can be easily and safely provided in a skilled nursing facility (SNF). IRF admission is not medically necessary based on lack of medical complexity and nursing needs and high functional level. Document does not support the necessity for admission to IRF. While you may benefit from continued physical therapy (PT), and occupational therapy (OT), your rehabilitation needs can be safely provided in an alternate and low intensity setting such as in an SNF.  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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewings radiographic images (x-ray) (D0274), provided on September 1, 2021.  You asked the Plan to pay for the bitewing x-rays. You say that the service was medically necessary. The Plan denied your request. The Plan says you have exceeded the maximum frequency allowed for this service.  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 pay for the bitewings radiographic images (x-ray) (D0274), provided on September 1, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for the anesthesia services (01936) provided on July 15, 2021.  You asked the Plan to pay for code 01936. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered 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. In this case, the CPT Code Manual definition of code 01936 is Anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic.  We find that CPT code 01936 is supported in the medical record. Specifically, the documentation provided describes the anesthesia services were provided as billed. The Plan has not provided any Medicare guidelines showing that the anesthesia services cannot be paid as billed. Based on this information, we decided that Medicare rules for coverage of code 01936 have been met. Therefore, we decided that the Plan has to pay for the anesthesia services (01936) provided on July 15, 2021.   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: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.  

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical documentation submitted with the appeal request does not demonstrate medical necessity.  

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 scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found the enrollee has interval development of abnormal fluid collections as described per clinical summary in the setting of two recent cancer diagnoses. The standards of care and current guidelines support the medical appropriateness and necessity of repeat CT imaging as requested for follow-up management of the enrollee's clinical course as described.  

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 scan have been met. Therefore, we decided that the Plan has to pre-approve computed tomography (CT) scan of the abdomen and pelvis for the enrollee.   

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 pre-approve replacement of the prosthetic leg.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not cover replacements for items that are still under warranty.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of  loss or irreparable damage or irreparable wear to the current K3 foot, which is under five years old, according to the treating medical provider progress notes. The replacement foot would also be a K3 level. The criteria for a complete replacement prosthetic leg with foot is not medically necessary and exceeds your needs per Medicare Benefit Policy Manual, Chapter 15, Section 100.2.  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 replacement of the prosthetic leg.