Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the GeneSight Psychotropic Assay (81479) provided on February 12, 2021.
You asked the Plan to pay for the GeneSight Psychotropic Assay (81479). You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for the GeneSight Psychotropic Assay (81479) by a contract provider. The file does not show that the plan provided notice that the GeneSight Psychotropic Assay (81479) would not be covered. Under Medicare rules, this means the GeneSight Psychotropic Assay (81479) is considered approved by the plan. Therefore, we decided that the Plan has to pay for the GeneSight Psychotropic Assay (81479) provided on February 12, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology and neuromuscular services represented by
codes 95939, 95938, 95908 and 95886 provided on January 14, 2021.
You asked the Plan to pay for the neurology and neuromuscular services. You say that you would like the Plan
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered
as billed.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The file shows that the neurology and neuromuscular services were
billed with POS code 15 for a mobile unit; however, the records show that the services were performed in a
facility setting. Therefore, we decided that the Plan does not have to pay for the neurology and neuromuscular
services represented by codes 95939, 95938, 95908 and 95886 provided on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD).

You asked the Plan to pre-approve an EGD. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 an EGD. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested service is not medically necessary or reasonable, as defined by Medicare rules, for the enrollee's clinical situation. The elements of the coverage rule are not satisfied. The requested service is not recommended at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an EGD have not been met. Therefore, we decided that the Plan does not have to pre-approve an esophagogastroduodenoscopy (EGD).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve continued services. You say that the enrollee needs to be able to remove the BiPAP device by himself. The Plan denied your request. The Plan says daily skilled care was no longer needed.

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 continued services. Our physician reviewer found that the enrollee is at a maximal assist level for rolling, sitting up, and repositioning. He is at moderate assist for lying down. He does not have documented skilled nursing needs. He does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) 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 LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the benefit, including the Lifetime Reserve days, have been exhausted. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that hospitals are required to notify patients who have already used or will use 90 days of benefits in a benefit period that they can elect not to use their reserve days for all or part of a stay. 

We looked at the file and Medicare rules. 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (80307) provided on May 20, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says there were network providers available.
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 service
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 lab services (80307) provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement of muscle and/or fascia (11043) rendered by the out-of-network (OON) provider on April 20, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an 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. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the debridement of muscle and/or fascia (11043) rendered by the out-of-network (OON) provider on April 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (13121) provided to the enrollee on January 15, 2021.

You asked the Plan to pay for . You say that this should be paid for. The Plan denied your request. The Plan says Current Procedural Terminology (CPT) code 13121 59 (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 13121 is "Repair, complex, scalp, arms, and/or legs." 

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 . Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the denied code is reported by the size of the wound. The operative report does not include any documented of wound size. Therefore, the appropriate code to report cannot be confirmed. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (13121) provided to the enrollee on January 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.

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 is currently undergoing treatment at an ACH. Initially admitted for alcohol withdrawal, the enrollee suffered a cardiac arrest and was intubated/ventilated. He subsequently received a tracheotomy and has since been weaned from the ventilator. The enrollee is noted to be minimally responsive, despite being off sedation. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 

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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says medical issues appear to have been essentially stabilized.
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 the admission. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or 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 skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on November 17, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 95957, 95910, 95886, and 95999 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. 

In this case, the CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). The definition of code 95910 is nerve conduction studies; 7-8 studies.

The definition of code 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The definition of code 95999 is unlisted neurological or neuromuscular diagnostic procedure. 

We find that CPT codes 95957, 95910, 95886, and 95999 are not supported in the medical record. Specifically, there is no documentation of digital analysis of EEG to support code 95957. There is no documentation of 7-8 nerve conduction studies to support code 95910. There is no documentation of needle electromyography to support code 95886. There is no documentation of an unlisted neurological or neuromuscular diagnostic procedure to support code 95999.

Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services rendered on November 17, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the knee (73560), x-ray exam of the hip
(73502), the set-up of portable x-ray equipment (Q0092), and the transportation of portable x-ray equipment
(R0070) rendered by the out-of-network (OON) provider on April 13, 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 an 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.
The 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 x-ray exam of the knee (73560), x-ray exam of the hip (73502), the set-up of
portable x-ray equipment (Q0092), and the transportation of portable x-ray equipment (R0070) rendered by the
out-of-network (OON) provider on April 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

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. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

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: Imaging
Decision: Partially Favorable

We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. We decided that the Plan does not have to pre-approve a CT scan of the chest.
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis and CT scan of the chest. You say that the services are necessary. The Plan says that based on the documentation provided, coverage criteria has not been met.
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Part C Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. Our reviewer says that the requested service is considered medically reasonable and necessary in this case.
Our physician reviewer found the CT of the abdomen and pelvis done April 14, 2021 had 2 findings of concern. First, there was a stable cystic 1 cm mass in the pancreatic head which would qualify for close surveillance as cystic neoplasm would be in the differential diagnosis but unrelated to bladder cancer. Second, the report describes diffuse bladder wall thickening such that post radiation cystitis is likely but recurrent tumor could not be excluded. For these two reasons the requested CT of the abdomen and pelvis should be approved.
Therefore, we decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis.
We also decided that the Plan does not have to pre-approve a CT scan of the chest. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has no signs of chest disease and surveillance CT of the chest more often than annually for stage II bladder cancer does not comply with NCCN guidelines.
Therefore, we decided that the Plan does not have to pre-approve a CT scan of the chest.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Memantine.

You asked the Plan to pre-approve Memantine. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.

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 Memantine.

Benefits for Memantine 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled services are no longer required.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or 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 skilled nursing facility 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).