Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 62320 provided on September 20, 2021.  You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly and should be paid. The Plan denied your request. The Plan says the records are insufficient to support payment for these services.  The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain documentation requirements must be met. The documentation must include the legible signature of the physician or non-physician practitioner responsible for providing the care to the patient.  In addition, the procedure report should clearly document the indications and the medical necessity for the blocks along with the pre and post percent pain relief achieved immediately post-injection.  The medical records in this case do not meet Medicare's documentation requirements.  Specifically, the record is not signed and there is no notation of the percent of pain relief achieved either before or after the injection.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure code 62320 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 62320 provided on September 20, 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 he enrollee's admission to a LTACH is medically necessary. The Plan denied your request. The Plan says it is not safe for enrollee to leave the hospital at this time.  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 now tolerating trach collar following weaning but is still lethargic with a poor prognosis and requiring vasopressor support.   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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on August 2, 2021.  You asked the Plan to pay for the laboratory 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 providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in an Off Campus-Outpatient Hospital setting POS 19. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on August 2, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic mammography services (77065) provided on June 7, 2021.  You asked the Plan to pay for the diagnostic mammography services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 77065 and 77066.  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 77065 is a column II code to column I code 77066. This code pair does not allow for a 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 diagnostic mammography services (77065) provided on June 7, 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 this admission is medically necessary. The Plan denied your request. The Plan says the criteria for admission to the IRF setting have 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 while the enrollee may benefit from physical therapy (PT) and occupational therapy (OT), the enrollee's rehab needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing facility or in-home with PT and OT.  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: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for group psychotherapy (CPT code 90853) provided on April 7, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Evaluation and management by psychologists are covered by Medicare under the following conditions: *Provider must attempt to consult the attending or primary care physician about the services furnished and document the consent or declination date to consultations, and the date of consultations in the patient's medical record.  If consultation with the attending or primary care physician is unsuccessful, document in the patient's medical chart with the date and manner of notification to the physician does not consent. If attempts to consult directly with the physician are not successful, to notify the physician, within a reasonable time, that he or she is furnishing services to the beneficiary. There was no documented contact with the attending/primary care physician. Servicing provider and referring provider is the same person. It is important to note that the listing of a referring provider on the claim does not satisfy the Medicare required criteria for interacting with the attending physician. A referral form or reference to a copy of the report available to a physician does not satisfy the documentation criteria. Therefore, we decided that the Plan does not have to pay for group psychotherapy (CPT code 90853) provided on April 7, 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 appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.  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 the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee may need physical and/or occupational therapy, there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on February 16, 2021.  You asked the Plan to pay for the laboratory 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 providers must report services correctly.  We looked at the file and Medicare rules. Review of the file shows the claim was billed with an inappropriate place of service 11. According to claims history, the specimen was obtained in a psychiatric facility partial hospitalization POS 52. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a Group 2 standard power wheelchair (K0823) provided on February 26, 2021.  You asked the Plan to pay for a power wheelchair. You say that the item at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because title of the equipment at issue must be transferred to the enrollee after 13 months of rental.  The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power wheelchair have not been met. Specifically, after 13 months of continuous rental the enrollee has a purchase option. For payment to be made beyond 13 months of rental, the supplier would have to document that the purchase option was offered and either not responded to or declined. In this case, the record does not contain any such documentation. Therefore, we decided that the Plan does not have to pay for a Group 2 standard power wheelchair (K0823) provided on February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis (CPT code 0037U) provided on September 29, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the enrollee does not meet Centers for Medicare & Medicaid Services (CMS) guidelines for authorization and is considered not medically necessary.  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 service. Our physician reviewer found the review has determined that in this case the enrollee has moderately differentiated squamous cell lung cancer. The medical records provided do not meet the requirements listed in the NCD for Medicare coverage.  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 pay for the targeted genomic sequence analysis (CPT code 0037U) provided on September 29, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGP testing (CPT code(s): 81304, 81404, 81405, 81406, and 81408) provided on July 30, 2021.

You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.

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. 

As CGP testing is not defined as a targeted panel by MolDX; and is a test not currently satisfactorily described by any existing CPT code; to report a CGP testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use 1-unit only of CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes, or other unlisted code. Therefore, we decided that the Plan does not have to pay for the CGP testing (CPT code(s): 81304, 81404, 81405, 81406, and 81408) provided on July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spinal canal.

You asked the Plan to pre-approve MRI. You say that the enrollee is severely limited in ambulation and is having great difficulty and pain. The Plan denied your request. The Plan says the denial of authorization for this test is correct, because MRI is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically necessary. 

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 MRI. Our reviewer says that the enrollee does not meet the criteria for the requested MRI. Our physician reviewer found medical visit notes and physical examination records do not document specific lumbar spine signs or symptoms which would indicate a need for magnetic resonance imaging (MRI). No radiographic reports are included which would indicate necessity of further evaluation with MRI. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower spinal canal.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. It is not safe for the enrollee to leave the current setting. The necessary care is being provided in the current acute facility, and there is no clinical advantage in transferring to an LTACH at this time.

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 acute hypoxic respiratory failure due to pneumonia. The record indicates that the enrollee still requires high flow oxygen and ongoing acute care services. The enrollee is receiving acute care at the current facility, and these services 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve epidural injection services.

You asked the Plan to pre-approve epidural injection services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that more than 3 epidural steroid injections in a 6-month period is prohibited by Medicare rules.

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. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has denied the requested services based on Local Coverage Determination (LCD): Epidural Steroid Injections for Pain Management (L36920). However, this LCD is not valid for the state of South Carolina where these services will be performed. Therefore, we used LCD L39504 for the coverage determination. Notably in both LCDs, the documentation states "Epidural Steroid Injections (ESIs) are limited to a maximum of four (4) sessions per spinal region in a rolling twelve (12) month period." Nowhere in the documentation does it support the Plan's denial reason that only 3 epidural steroid injections are allowed per 6-month period. It appears that this language was used in an LCD that is now retired and not applicable for coverage. Therefore, we decided that the Plan has to pre-approve epidural injection services.

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: Step-Therapy
Decision: Favorable

 We decided that the Plan has to pre-approve use of Evenity.  You asked the Plan to pre-approve Evenity. You say that this medication is needed to adequately treat the enrollee's condition. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because the Plan requires a trial of Prolia or Reclast before it will approve Evenity.  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. Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The enrollee's contract with the Plan does not indicate that the Plan has implemented step therapy criteria that are applicable to Evenity. Although the Plan submitted a Medicare Part B preferred drug list, the Plan contract does not show that the enrollee is contractually obligated to try a preferred drug before using a non-preferred drug. The Plan did not provide any other rationale or evidence to support a denial of authorization for this drug. Therefore, the Plan has not shown that its decision to deny authorization for Evenity is correct or justified according to Medicare rules and the enrollee's contract with the Plan. Therefore, we decided that the Plan has to pre-approve use of Evenity.   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.  You asked the Plan to pre-approve SI joint RFA. You say that this is the last resort to resolve your pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this is considered experimental/investigational.  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 SI joint RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/investigational procedure because of the wide variation of efficacy in medical literature.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SI joint RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis 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 Eliquis 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.