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

We decided that the Plan does not have to pre-approve continuation of SNF care from January 29, 2022,
forward.
You asked the Plan to pre-approve SNF care. You say that you are being discharged and there will be no one
available to take care of you. You state your family was not given transitional support and have no way to
transport you. The Plan denied your request. The Plan says you no longer require skilled nursing or therapy
services on a daily basis and the continuation of SNF is not medically necessary.
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 there are no identifiable skilled nursing
service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or
therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an
inpatient basis in a 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 continuation of SNF care from January 29, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing provided on June 3, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for the OON drug testing. You say that this should be paid due to medical necessity.
The Plan denied your request. The Plan says the ordering provider and the rendering lab are OON with the
Plan. This was not emergent testing, and no authorization was obtained.
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 the definitive drug testing provided on June 3,
2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair and accessories you purchased on September
17, 2021.
You asked the Plan to pay for the wheelchair and accessories. You say that the items should be covered. The
Plan denied your request. The Plan says you purchased these items through a provider that is not enrolled in
Medicare.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for the wheelchair and accessories you
purchased on September 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydroxyzine pamoate for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Hydroxyzine pamoate for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication.
The record indicates that the enrollee has multi-level degenerative disease including severe foraminal stenosis at L4-L5 the level requested for treatment. The record does not state that the enrollee is indicated for operative intervention at no more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an upper extremity fracture orthosis 
(L3984) provided on June 30, 2021
.
You asked the Plan to waive the coinsurance for the upper extremity fracture orthosis. You say that the services 
should be covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the 
services provided.

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 20% 
coinsurance for Prosthetic devices and related supplies.
 
You have been asked to pay a 20% coinsurance for an upper extremity fracture orthosis (the allowed amount is 
$271.03 x 20% = $54.21). Upper extremity fracture orthosis falls within the Prosthetic devices and related 
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 coinsurance for an upper extremity 
fracture orthosis (L3984) provided on June 30, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the Guardant360 testing provided on April 21, 2021.

You asked the Plan to pay for the testing services. You say that the testing determines the best therapy option 
for late-stage cancer patients. The Plan denied your request. The Plan says that the unlisted code was submitted 
without a description.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.

We looked at the file and the rules. The testing services at issue was billed with CPT code 81479. The service 
line information on the claim provides a description as Guardant360 testing. Based on this information, we 
decided that the Medicare rules for coverage have been met. The Plan has not made reasonable and diligent 
efforts to gather and forward to us information regarding their decision to deny your request. Therefore, we 
decided that the Plan has to pay for the Guardant360 testing provided on April 21, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the dermatology services provided on December 8, 2020 by
an out-of-network (OON) provider.
You asked the Plan to pay for the OON dermatology services. You say that this was medically necessary care.
The Plan denied your request. The Plan says this was not an emergency visit and no authorization was obtained
to provide these services OON.
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 the dermatology services provided on December
8, 2020 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan states the enrollee's status is stable and improving and they are receiving medically necessary acute and/or critical care. The Plan states the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage. The Plan states they will continue to cover medically necessary acute and critical care at the current facility until the enrollee's condition is stable for transfer to an alternate level of care (such as a skilled nursing facility), or until the clinical circumstances change such that LTACH may be reconsidered.

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 the enrollee was admitted with an ST elevation myocardial infarction and required percutaneous revascularization. The record indicates that the enrollee is improving but still requires acute care services. The enrollee continues to receive acute care services, and these have not been denied.

The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99239) provided on February 25, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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 99239 is "Hospital discharge day management; more than
30 minutes".
We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that
more than 30 minutes of hospital discharge day management services were provided on the date of service in
question. 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 the services (99239) provided on February
25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on September 20, 2021.

You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you thought you were 
only having a deep cleaning. The Plan denied your request. The Plan says you have exhausted your benefit 
coverage 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, you are limited to 1 comprehensive 
oral exam every 3 years. The record shows that you received a comprehensive oral evaluation (D0150) on May 
19, 2021, and your comprehensive oral exam benefit has been exhausted. Therefore, we decided that the Plan 
does not have to pay for the comprehensive periodontal evaluation (D0180) provided on September 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from February 15, 2021, to February 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed diagnosis code is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis code A41.9. 

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. Our reviewer says that the use of diagnosis code A41.9 is not supported by the records provided. Our physician reviewer found that the documentation supported an admission for further evaluation and treatment of pneumonia in a patient with a past medical history to include COPD, CHF, and chronic respiratory failure with oxygen dependence. Diagnosis code A41.9 was not supported by the records provided. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from February 15, 2021, to February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services coded 81206 and 81292 provided on June 8, 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 the services are not payable as billed.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  

We find that CPT codes 81206 and 81292 are not supported in the medical record. Specifically, when a laboratory assays two or more genes in an enrollee in parallel, those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel. Review of the file shows that one code was not submitted for the services rendered. 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 coded 81206 and 81292 provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of a subcutaneous rhythm monitor, including
programming.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says there is no evidence of syncope.
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 the patient had no history of atrial fibrillation, nor were any significant cardiac arrhythmias
noted on electrocardiogram monitoring. Carotid artery disease was demonstrated, and his physician used the
term COVID stroke. A recent randomized clinical trial found that continuous monitoring for atrial fibrillation
with an implanted loop recorder (followed by treatment with oral anticoagulation if atrial fibrillation was
detected) was not superior to usual care in reducing stroke or systemic embolism among patients at high risk of
stroke but without a known prior history of atrial fibrillation). At this time, insertion of the monitor would not
be considered medically appropriate and necessary in the enrollee's clinical management.
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 insertion of a subcutaneous rhythm monitor, including programming.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria.

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 health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen (15) 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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 28, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 lab services provided on September 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (procedure code
99239) provided to the enrollee from December 22, 2020, to December 26, 2020.

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 a documented duration time of 31 minutes or more is required to support this code.

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 99239 is "Hospital discharge day management; more than
30 minutes."

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 the services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found the documentation did not include
medical documentation, and therefore confirmation of the procedure code billed cannot be verified. CPT 99239
is a timed code, and therefore documentation should support the time the service was provided. As no
evaluation and management documentation was submitted, this procedure code cannot be reviewed.

We looked at this coder'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 pay for hospital discharge day management services (procedure code 99239) provided to the enrollee
from December 22, 2020, to December 26, 2020.