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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that discharge home would not be safe at this time. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.    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 you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  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 skilled nursing facility (SNF) care.
Appeal type: Surgery
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 this procedure would give the enrollee great relief from pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee's pain is primarily axial.

The Plan follows Medicare rules. Medicare rules state that facet joint interventions may be covered under certain conditions, including that there is no non-facet pathology that could explain the source of the enrollee's pain. 

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 interventions. Our physician reviewer found the enrollee has multiple probable pain generators. The enrollee has failed back surgery syndrome as well as degenerative disc disease. Therefore, the request 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 facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hereditary genetic cardiac testing provided on March 27, 2021.  You asked the Plan to pay for the cardiac genetic testing. You say that this was medically necessary testing. The Plan denied your request. The Plan says Medicare does not cover this type of cardiovascular disease genetic screening.  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. The rules also require that the medical records confirm that Medicare coverage criteria are met.  We looked at the file and Medicare rules. We find that this testing was ordered by a physician without mention of how the results will be used in the management of a specific medical condition. The enrollee has an established relationship with the ordering physician; however, there is no mention in the progress note about the intent to provide this type of genetic testing or how the results would be used. This testing was ordered by a primary care physician for heart conditions, but it is documented that the enrollee is under the care of a cardiologist for these conditions. As such, we find that the records do not confirm that coverage criteria have been met.   Based on this information, we decided that Medicare rules for coverage of the cardiac genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for the hereditary genetic cardiac testing provided on March 27, 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 you can only put 50% of your weight on your legs and are able to do 3 hours of therapy per day. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.    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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an intensive rehabilitation therapy program. While you require physical and/or occupational therapy, you do not require an intensive rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate.  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 the Plan does not have to pay for medical services provided to the enrollee on October 14, 2020.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations. Code 99153 has a Professional Component (PC)/Technical Component (TC) indicator of 3, and may not be paid if furnished to a hospital inpatients or patients in a hospital outpatient department. A corrected claim is required.   The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, code 99153 cannot be paid as billed due to the enrollee's treatment status. A more appropriate coded is used for this service. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for medical services provided to the enrollee on October 14, 2020.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve Aranesp.  You asked the Plan to pre-approve Aranesp. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.  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 Aranesp. Our reviewer says that the medication is medically necessary. Our physician reviewer found the Food and Drug Administration has stated that the requested drug is indicated for the enrollee's condition. The elements of the coverage criteria are satisfied. The requested service is recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have been met. Therefore, we decided that the Plan has to pre-approve Aranesp.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for assistant surgery services provided to the enrollee on  July 9, 2021 and billed under code 19301.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan follows Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules say that for procedures with an assistant surgery indicator of 0, the payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code19301 The Medicare Fee Schedule Database contains a surgical indicator of 0 for this procedure. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for assistant surgery services provided to the enrollee on July 9, 2021 and billed under code 19301.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services provided to the enrollee on May 5, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the place of service code listed on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on May 5, 2021and received by the lab on May 6, 2021. Therefore, the billed code cannot be verified.  It is noted multiple attempts were made to obtain additional information from the provider. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, this claim has been submitted with an invalid place of service code. Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on May 5, 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 enrollee will have a better recovery at the IRF. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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.  While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation therapy program. Care as the skilled nursing facility level appears to be appropriate.  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 continued inpatient psychiatric care as of November 29, 2021.

You asked the Plan to pre-approve inpatient psychiatric care. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for continued inpatient psychiatric level of care is correct, because the enrollee is stable and can be discharged to a lower level of care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care as of November 29, 2021. Our physician reviewer found it is not expected that the enrollee will improve in a reasonable period of time after the date in question as the enrollee does not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats of safety. It does not appear medically necessary to have care provided at the inpatient acute level of care rather than 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 inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care as of November 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).

You asked the Plan to pre-approve therapeutic CGM. You say that your numbers change all the time, you administer insulin based on what your readings are, in addition to twice daily injections. The Plan denied your request. The Plan says you do not meet the Medicare criteria for a therapeutic CGM.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that you do not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, and have had an in-person visit with your treating physician to assesses adherence to the CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre therapeutic continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex procedure.  You asked the Plan to pre-approve Vertiflex. You say that this procedure will help you have a better quality of life. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is insufficient evidence of the efficacy of this procedure.  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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for debridement services provided to the enrollee on March 27, 2021.  You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. We asked our coder 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 this service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found while the operative report describes the size of the wound debrided, the report does not include enough detail to confirm the depth of debridement performed, and therefore, this procedure cannot be verified.   We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for debridement services provided to the enrollee on March 27, 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 due to your condition you could hurt yourself, and need to be monitored daily by a licensed professional. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While you may require physical and/or occupational therapy, there is no documented need for an intensive rehabilitation therapy program. Care at the skilled nursing facility level appears to be appropriate. 

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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing provided on January 15, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay this claim. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 genetic testing provided on January 15, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635 and 64636).  You asked the Plan to pre-approve RFA. You say that the service is medically necessary. The Plan denied your request. The Plan says the enrollee has already received two sessions in the previous twelve months.  The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Specifically, the documentation provided indicated the enrollee has exhausted the allowed frequency for this service. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) (64635 and 64636).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the $90 copayment charged for emergency room services provided to the enrollee from February 14, 2021 to February 16, 2021.  You asked the Plan to waive this copayment. You say that you do not believe this copayment is correct. The Plan denied your request. The Plan says the records show while the enrollee did spend overnights in the hospital, the treatment status for this stay was observation care and not inpatient care.  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 enrollee's contract with the Plan clearly says that enrollees must pay $90 copayment for emergency room services. The enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the $90 copayment charged for emergency room services provided to the enrollee from February 14, 2021 to February 16, 2021.