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

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. At the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. You have no acute nursing care needs. Based upon your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. You need physical and occupational therapy in an alternate and low intensity level. While you may benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in an skilled nursing facility. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on July 12, 2021.  You asked the Plan to waive the copayment for laboratory services. You say that you disagree with the charges because the laboratory services were part of your annual wellness exam. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $25 copayment for laboratory services.   You received laboratory services on July 12, 2021. Laboratory services are not included in annual wellness exams. Therefore, you are responsible to pay the $25 copayment.  You have been asked to pay a $25 copayment for laboratory services. Laboratory 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 laboratory services provided on July 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure code 0242U) provided to the enrollee on April 16, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 0242U (1 Unit) remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 0242U is "Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements." 

We find that CPT code 0242U is not supported in the medical record. Specifically, Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (procedure code 0242U) provided to the enrollee on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the periapical first radiographic image (D0220), limited oral evaluation (D0140), and resin-based composite (D2335), provided on June 25, 2021.  You asked the Plan to pay for the periapical first radiographic image, limited oral evaluation, and resin-based composite. You say that the services should be covered. The Plan denied your request. The Plan says you did not have any supplemental dental coverage at the time services were rendered.  Medicare generally does not cover dental services. The Plan follows the same rule.  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periapical first radiographic image (D0220), limited oral evaluation (D0140), and resin-based composite (D2335), provided on June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic imaging of the heart (quantitative calcium
scoring) (CPT 75571), provided on August 10, 2021.

You asked the Plan to pay for a diagnostic imaging of the heart. The Plan denied your request. The Plan says
based on a review of the information received, it was determined that quantitative calcium scoring is not a
covered service. Calcium scoring reported in isolation is considered a screening service and is considered not
medically necessary.

The Plan must follow Medicare rules. Medicare rules say that quantitative calcium scoring is not a covered
service and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a
screening service.

We looked at the file and Medicare rules. Medicare says quantitative calcium scoring is not a covered service
and will be denied as not medically necessary. Calcium scoring reported in isolation is considered a screening
service. Based on this information, we decided that Medicare rules for coverage of a diagnostic imaging of the
heart have not been met. Therefore, we decided that the Plan does not have to pay for a diagnostic imaging of
the heart (quantitative calcium scoring) (CPT 75571), provided on August 10, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two physical therapy (PT) visits in the home provided on July 22, 2021, and July 23, 2021.  You asked the Plan to pay for the PT visits. You say that you believe that these visits were medically reasonable and necessary. The Plan denied your request.    The Plan says the documentation provided does show progress towards goals or that the enrollee is unable to perform therapeutic activities except under the supervision of a physical therapist.  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 PT visits. Our reviewer says that the home health services were not medically necessary. Our physician reviewer found the documentation does not support that the enrollee required additional skilled rehabilitation services to provide treatment that is medically necessary. The enrollee did not require additional rehabilitation services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. Our reviewer found that the enrollee had been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Our reviewer also found that the enrollee had functional improvement by July 22, 2021 and should have been independent with a home exercise program.  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 PT visits have not been met. Therefore, we decided that the Plan does not have to pay for the two physical therapy (PT) visits in the home provided on July 22, 2021, and July 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.

You asked the Plan to pre-approve Opdivo. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 Opdivo. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of stage IV metastatic gastric cancer, PDL-1 negative. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy you had at an ambulatory surgical center on May 4, 2021.  You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that your doctor asked you to send in a stool sample for colon cancer screening. The result of this test suggested that you get a colonoscopy. You said that both of these services are preventive colon cancer screenings and should be fully covered. The Plan denied your request. The Plan says you were charged this copayment correctly. That they contacted your doctor who confirmed that this was not a screening, but a diagnostic procedure.  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 $250 copayment for outpatient surgery or procedures in an ambulatory surgical center.   You have been asked to pay a $250 copayment for the diagnostic colonoscopy. This was billed as a diagnostic, not screening, procedure. In addition, the Plan confirmed with your doctor that this procedure was ordered as a diagnostic, not screening, procedure. Diagnostic colonoscopies are considered surgical services. 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 diagnostic colonoscopy you had at an ambulatory surgical center on May 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet joint injections (64490 and 64491) provided on May 17, 2021.

You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says procedure codes 64490 and 64491 have not met the associated Diagnosis Code relationship criteria.

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 64490 and 64491 are not supported in the record. Specifically, the applicable Local Coverage Article includes a list of appropriate diagnosis codes for the CPT codes billed. The diagnosis codes listed on the claim are included in the list of appropriate diagnosis codes to support medical necessity. Based on this information, we decided that Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for the facet joint injections (64490 and 64491) provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acupuncture.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the file shows that the acupuncture is not being requested for treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pre-approve acupuncture.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve CoreText/ProText, per cc (amniotic liquid allograft injection, derived from human amniotic tissue).  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says very little clinical information was received about the illness.  The Plan must follow Medicare rules. Medicare rules state that allogenic and autologous stem cell transplants are covered under Medicare for specific diagnoses.  A review of the case file shows that no medical information other than a diagnosis were provided. The diagnosis is bilateral osteophyte (bone spurs), or more simply, knee pain. Knee pain is not traditionally a covered diagnosis for this request. There is no records to indicate any other diagnoses that could be managed by the request for amniotic liquid allograft injection. 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 CoreText/ProText, per cc (amniotic liquid allograft injection, derived from human amniotic tissue).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inherited cardiomyopathy genomic sequence analysis panel (81439) provided July 3, 2021.  You asked the Plan to pay for the laboratory services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk screening assessment genomic testing panels for suspected or documented cardiovascular disease.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the inherited cardiomyopathy genomic sequence analysis panel (81439) provided July 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography services coded 70450 provided on July 22, 2021.  You asked the Plan to pay for the computed tomography. 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 separately 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 70450 for the computed tomography is a column II code to column I code 70450 for 70496. 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 computed tomography services coded 70450 provided on July 22, 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 are lying in bed and need to get up to do physical therapy. You say that the acute rehabilitation level of care is medically necessary. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care 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 at the current medical stability and lack of medical complexity, there is no need for physical medicine and rehabilitation (PMR) physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. The enrollee has no acute nursing care needs. Based upon the enrollee's current level of function, she does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. With preadmission status requiring 24/7 assist, and chronic medical problems, she will not be able to make a significant progress in a predicted and reasonable period of time in an IRF. Her functional and rehabilitation needs can be addressed just as well in a skilled nursing facility (SNF.) The enrollee needs physical therapy and occupational therapy in an alternate and low intensity level. While the enrollee may benefit from physical therapy and occupational therapy, her rehab needs can be safely met 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, manual therapy technique, and manual manipulation of the spine provided by a chiropractor on June 21, 2021 and June 28, 2021.

You asked the Plan to pay for office visit, manual therapy, and manual manipulation. You say that there are discrepancies with these claims and the Plan should remove your responsibility for payment. The Plan denied your request. The Plan says the denial of payment for the office visit and manual therapy charges is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that the copayment amounts you are being charged are correct.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The rules say that a Plan must disclose to its enrollees all cost-sharing benefits. Your contract with the Plan clearly says that you must pay $20 copayment for each in-network visit for covered chiropractic services. 

The records show that the office visit and manual therapy technique services at issue are not manual manipulation of the spine. Therefore, these services are not covered by Medicare or the Plan when performed by a chiropractor. Additionally, you have been asked to pay $20 copayment per visit for the covered manual manipulation of the spine. There were two visits, resulting in a copayment amount of $40. Therefore, we decided that the Plan does not have to pay for an office visit, manual therapy technique, and manual manipulation of the spine provided by a chiropractor on June 21, 2021 and June 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the WATS testing provided on May 24, 2021.  You asked the Plan to pay for the testing services. You say that the testing is standard of care for the enrollee's condition. The Plan denied your request. The Plan says the service is not being used as a companion diagnostic.  The Plan must follow Medicare rules. Medicare rules say that the information submitted must corroborate the documentation in the beneficiary's medical documentation  The file shows that a WATS 3D biopsy was ordered for surveillance of untreated Barrett's Esophagus. We looked at the file and the rules. We find that the testing is not supported in the medical record. Specifically, there are insufficient medical records that clearly document other types of testing, stool, etc. that have been previously completed. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the WATS testing provided on May 24, 2021.