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 IRF services are medically necessary for the enrollee to build strength and care for herself. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided in a lower level of care.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided in an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's needs can be met in a lower level of care.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on September 29, 2021.  

You asked the Plan to pay for the endodontic therapy. You say that you paid out of pocket for this service and would like some help from your dental plan to cover this service. The Plan denied your request. The Plan says this service is not a covered expense under your dental plan.  

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the endodontic therapy (D3320) provided on September 29, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

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 you appear to be improving and stable, however, additional short-term acute care services are still needed that can be safely received at the current facility until appropriate lower level of care placement is secured. There are no services at the LTACH that you require that are not already available and covered at the current facility.    

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: 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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

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 appears to be improving, however, additional short-term acute care services are still needed that can be safely received at the current facility until completed. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered again when treatment has completed.    

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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the long term care (LTC) provided in a skilled nursing facility (SNF) from June 22, 2021, to July 21, 2021.  

You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services.  

The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF care have not been met. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the long term care (LTC) provided in a skilled nursing facility (SNF) from June 22, 2021, to July 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device and accessory (E0675, E0673).  

You asked the Plan to pay for a pneumatic compression device. You say that this item was medically necessary and reasonable. The Plan denied your request. The Plan says this item is not covered by Medicare or by the Plan.  

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.  

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and accessory (E0675, E0673).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing services (81529) provided on September 28, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for genetic testing services. You say that this test was denied in error and want it to be reprocessed and paid in according with the Medicare Manage Care Manual guidelines. You also say that this test was ordered by the patient's treating physician. The Plan denied your request. The Plan says this provider is not a network provider, and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they approved in advance.  

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 genetic testing services (81529) provided on September 28, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a specialist office visit (99204) provided on October 8, 2021.  

You asked the Plan to waive the copayment for the specialist office visit. You say that the services should be covered. The Plan denied your request. The Plan says the cost-sharing 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 $45 copayment for Physician/Practitioner services, including doctor's office visits.     

You have been asked to pay a $45 copayment for the specialist office visit. The record indicates that rendering provider is a specialist. 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 a specialist office visit (99204) provided on October 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve ROMtech portable connect device (CPT code E1399), for the enrollee.  

You asked the Plan to pre-approve the device. You say that the prescribed equipment will aid in the symptomatic relief of pain, increase local blood flow, stimulate soft tissue healing, increase range of motion, aid in muscle reeducation and the relaxation of muscle spasms. You state the enrollee's use of this equipment in their home will thus minimize the necessity for narcotic pain medications. You state a home unit as part of the enrollee's treatment protocol will facilitate their quicker return to functional restoration and participation in the activities of daily living. The Plan denied your request. The Plan says a ROMTech portable connect device is not used to take care of a medical need.  

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.    

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve ROMtech portable connect device (CPT code E1399), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ConfirmMDx Epigenetic Molecular Assay.  You asked the Plan to pay for the ConfirmMDx Epigenetic Molecular Assay. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says there is no documentation that the member has undergone a previous cancer-negative prostate biopsy within 24 months and is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that the ConfirmMDx is covered when specific criteria are met.   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 ConfirmMDx Epigenetic Molecular Assay. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee underwent a prostate biopsy in August 2021 that was benign.  The record does not indicate that a repeat biopsy is being considered at the time of the request. 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 ConfirmMDx Epigenetic Molecular Assay have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx Epigenetic Molecular Assay.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 99072 provided on September 16, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on additional documentation. The Plan denied your request. The Plan says this claim is bundled into payment for other services not specified according to Medicare coding regulations.  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 99072 is additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease.  We looked at the file and Medicare rules. In this case, code 99072 has a Status Code of "B" under the Physician Fee Schedule. This indication means that payment for covered services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99072 provided on September 16, 2021.
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 the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  

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 you appear to be improving; however, additional short-term acute care services are still needed that can be safely received at the current facility until completed. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.    

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography (MRA) scan of the head (70544) provided on September 13, 2021.  

You asked the Plan to pay for MRA scan services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the claim has not been billed with an appropriate modifier.  

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 70544 is a column II code to column I code 70551. 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 magnetic resonance angiography (MRA) scan of the head (70544) provided on September 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99213) provided on June 17, 2021, by an out-of-network (OON) provider.  

You asked the Plan to pay for an office visit. You say that you say that you are appealing with supporting records. The Plan denied your request. The Plan says both the servicing provider and the referring provider are not participating providers with the Plan.  

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 an office visit (99213) provided on June 17, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Prolia.  You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy requirements have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Prolia. Our reviewer says that the requirements for coverage of Prolia have not been met. Our physician reviewer found the Plan requires a trial of an oral bisphosphate and zoledronic acid before they will approve the requested drug. While the record shows that the enrollee has failed oral bisphosphonates, it does not show that the enrollee has tried zoledronic acid. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from zoledronic acid.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is not medically necessary.  

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.   

Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the documentation provided supports the need 
for SNF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The 
Plan says that the care needed can be safely received in another setting.

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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation supporting a 
need for skilled nursing services. The enrollee does require skilled therapy services, but not on a daily basis. 
The enrollee does not require the services needed on an inpatient basis, only in a SNF setting. Services in a 
long-term care facility on a part-time basis appear appropriate in this case.

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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services.