Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of long-term acute care hospital (LTACH) services.  You asked the Plan to pre-approve LTACH services. You say that you cannot care for yourself and require constant care for your medical needs. You cannot stand or ambulate on your own and require maximum assistance with position changes. The Plan denied your request. The Plan says you are requesting pre-approval for continuation of an LTACH admission that began on October 28, 2021. You became a member of the Plan starting on December 1, 2021. In this circumstance, the Plan is not liable for payment for these services, as you were not enrolled with this organization on the date of admission.  The Plan must follow Medicare rules. Medicare rules say that if the provider is a long-term care hospital and the enrollee changes Medicare Advantage (MA) status during an inpatient stay for an inpatient institution, the enrollee's status at admission or start of care determines liability. If the hospital inpatient was not an MA enrollee upon admission but enrolls before discharge, the MA organization is not responsible for payment.   We looked at the file and Medicare rules. Documentation shows that you were admitted to the LTACH on October 28, 2021, and enrolled with the MA Plan on December 1, 2021. Based on this information, we decided that Medicare rules for coverage of LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of long-term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (81403, 81404, 81405, 81406) provided on July 30, 2020.  You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS).   We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (81403, 81404, 81405, 81406) provided on July 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.  You asked the Plan to pre-approve additional home health skilled nursing visits. You say that the requested services continue to be medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 additional home health skilled nursing visits. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found that the enrollee does not have documented skilled nursing needs (i.e. IVs, complex wound care, new ostomy).  As such, the requested, ongoing, home health skilled nursing 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 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional home health skilled nursing visits.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram services (93000) provided on May 19, 2021.  You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim reprocessed based on the documentation provided. The Plan denied your request. The Plan says an appropriate modifier was not billed with these services as required by Medicare rules.  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 93000 is a column II code to column I code 93224. This claim has not been billed with an appropriate modifier to bypass the edit. 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 electrocardiogram services (93000) provided on May 19, 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 using this monitor will give you an accurate reading and more control over your blood sugar levels. 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, have had an in-person visit with their treating physician to assesses adherence to their 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 7 additional home health physical therapy visits.  You asked the Plan to pre-approve home health physical therapy. You say that these additional home health physical therapy services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 home health physical therapy. Our reviewer says that the requested home health services are not medically reasonable and necessary. Our physician reviewer found Based on the medical records provided there is no documentation that the seven denied home health skilled therapy sessions are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. Provided records do not clarify why the six approved visits with the option to approve further therapy based on progress notes would be inadequate to treat the enrollee's condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 7 additional home health physical therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. Based on the records provided, it does not appear that the enrollee requires an intensive hospital setting such as an LTACH. The enrollee's continued care can be provided in the current inpatient setting or in a skilled nursing facility.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.  The requested LTACH services medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an interspinous stabilization device.  You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative measures. The Plan denied your request. The Plan says the device is considered experimental.  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 requested services. Our physician reviewer found that interspinous stabilization devices are experimental. More research is needed to show safety and efficacy of the devices. Therefore, the request is not considered medically reasonable or necessary.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous stabilization device.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing (80307) provided on March 4, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for drug testing. You say that this is supported in the records. 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 drug testing (80307) provided on March 4, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 10 home health aide visits.  You asked the Plan to pre-approve 10 home health aide visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy.   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 10 home health aide visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found home health aide (HHA) services are not shown to be medically necessary and reasonable to treat an illness or injury. As such, the requested home health services are not coverable.     We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 home health aide visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 home health aide visits.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an out-of-network referral to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are in-network skilled nursing facilities readily available and accessible.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an out-of-network referral to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services (0242U) provided on April 12, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says these services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting which is not what the billed POS indicates. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services (0242U) provided on April 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (0242U) provided on April 22, 2021.  You asked the Plan to pay for laboratory services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an on campus-outpatient hospital setting which is not what the billed POS indicates. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (0242U) provided on April 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for biceps tenodesis (29828) and debridement (29823-59) provided on March 5, 2021.  You asked the Plan to pay for biceps tenodesis and debridement. You say that these procedures are documented. The Plan denied your request. The Plan says these codes are 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. The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  In this case, the CPT Code Manual definition of code 29828 is arthroscopy, shoulder, surgical; biceps tenodesis. The definition of 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]).   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 biceps tenodesis and debridement. Our reviewer says that code 29828 is not supported. Our reviewer found the operative report does not include details of biceps tendon to confirm this procedure was performed. The operative report documents "biceps thermal tenodesis was performed until the biceps could sit in the intertubecular groove and it was stable in this position."   The documentation should include the details of the procedure to confirm procedure was performed.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 29828 have not been met. We also found that there is insufficient documentation of code 29823 as a distinct procedural service. The records do not document that this was performed at a different site from other procedures. Therefore, we decided that the Plan does not have to pay for biceps tenodesis (29828) and debridement (29823-59) provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve the CGM. You say that it is felt that this is medically necessary. The Plan denied your request. The Plan says the Medicare criteria are not met.  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 the enrollee does not perform blood glucose testing at least four times per day and does not use insulin with at least three daily administrations. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a microprocessor knee (Freedom Quattro) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this request exceeds the enrollee's need and is not reasonable and 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 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 the requested items exceed the enrollee's medical need as the  documentation does not support that this enro0llee cannot complete his activity with a standard K3 mechanical knee.  The prosthetist notes recommend the Proteor Quattro or similar knee. The Proteor Quattro or similar knee also exceed this enrollee's medical need as a review of this knee indicates that this knee is IP67 tested for occasional submersion in water. The knee has patient and Prosthetist Apps (available in both  iOS and Android) and 19 out of 20 programmable modes including a golf mode. There is no indication or medical need that this enrollee requires this knee to play golf, needs to submerge the knee in water, or requires an app to control his knee.  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 microprocessor knee (Freedom Quattro) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychosocial rehabilitation services, per 15 minutes (H2017) rendered by an out-of-network (OON) provider from July 26, 2021, through August 5, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by the out of network provider, without 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 has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  You are not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the psychosocial rehabilitation services, per 15 minutes (H2017) rendered by an out-of-network (OON) provider from July 26, 2021, through August 5, 2021.