Persius/hicric huggingface dataset:
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 have not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available and covered at the acute care hospital where they are currently receiving care. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 radiology services (70450) provided to the enrollee on April 28, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not 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. In this case, the CPT Code Manual definition of code 70450 is "Computed tomography, head or brain." 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 when CPT 70450 is billed with CPT 70496 for the same date of service, an appropriate modifier must be attached to identify a distinct procedure. 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 radiology services (70450) provided to the enrollee on April 28, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on June 17, 2020.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare and was ordered by the enrollee's treating physician to guide them through the process of selecting appropriate treatment. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because the enrollee did not meet the Medicare criteria for this testing.
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 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 has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The documentation submitted does not include prior notice from the Plan that this testing would not be covered. Without this information, we cannot determine whether the lab order made constituted plan-directed care. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for genetic testing provided on June 17, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on April 19, 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 billed are not payable.
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. Review of the file shows that the requisition/order or documented requested and the physician/exam notes that are needed in order to determine the clinical utility of the testing rendered were not submitted. This means that the laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of Alzheimer's disease. She was evaluated on June 3, 2021 for short-term memory loss. The medical records from this visit state she has cognitive dysfunction with suspect for some form of degenerative process, possibly Alzheimer's dementia. Aduhelm is indicated for the treatment of Alzheimer's disease in patients with mild cognitive impairment or the mild dementia stage of the disease. The documentation is insufficient to confirm a diagnosis of Alzheimer's disease in this enrollee. The documentation is insufficient to demonstrate that Aduhelm is medically reasonable and necessary for the enrollee 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the application of a cast; elbow to finger (29075) provided on June 9, 2021.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $275 copayment for Medicare-covered outpatient hospital and observation services.
You have been asked to pay a $216.60 copayment for the Medicare-covered outpatient hospital service provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the application of a cast; elbow to finger (29075) provided on June 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular panel (81407, 81408, 81439, 81479) provided on October 28, 2020.
You asked the Plan to pay for a hereditary cardiovascular panel. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular panel have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular panel (81407, 81408, 81439, 81479) provided on October 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement of a portable oxygen concentrator.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the provider has not completed a new order for equipment or submitted the documentation to reaffirm medical necessity for an oxygen concentrator replacement.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep. 

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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the records provided are a visit note from 11 months ago. These records do not mention a portable oxygen concentrator, and there is no order in the record. Apparently, the unit already provided is still under warranty. There is no information about whether that unit is broken or lost. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve replacement of a portable oxygen concentrator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87506 provided on March 5, 2021.

You asked the Plan to pay for the infectious agent detection by nucleic acid services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 87506 is infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.

We find that CPT code 87506 is not supported in the medical record. Specifically, the documentation supports that more than 11 pathogens were provided. This code only supports 6-11 pathogens. Therefore, this code is not correctly billed. Based on this information, we decided that Medicare rules for coverage of the infectious agent detection by nucleic acid services have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid services coded 87506 provided on March 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator.

You asked the Plan to pre-approve the concentrator. You say that this is medically necessary. The Plan denied your request. The Plan says the documentation received does not indicate that lighter portable oxygen tanks would not satisfy portable oxygen needs within the home.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

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 concentrator. Our reviewer says that the requested concentrator is not medically reasonable or necessary. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD) and are on home oxygen supplementation. There is no documentation that portable compressed oxygen tanks will not meet your needs for mobility within the home. Medicare does not cover a portable concentrator for the purposes of travel or activity outside the home. 

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 concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services (99232) provided February 3, 2021 to February 4, 2021.
You asked the Plan to pay for the hospital care services. You say that submitting the requested documentation to support CPT code 99223 and 99232. Please review and reprocess for payment. The Plan denied your request. The Plan says the records do not support the service 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. In this case, the CPT Code Manual definition of code 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded
problem focused interval history, an expanded problem focused examination and medical decision making of moderate complexity. We find that CPT code 99232 is not supported in the medical record. Specifically, the limited medical records provided do not support services for 99232. Complete medical records are still needed to support the services. The records show that the Plan made multiple attempts to obtain the medical records without success. Based on this information, we decided that Medicare rules for coverage of the hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services (99232) provided February 3, 2021 to February 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.
You asked the Plan to pre-approve a semi-electric hospital bed. You say that this item is medically necessary for your condition. The Plan denied your request. The Plan says your medical records do not show you need to change her body position quickly or frequently.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 a semi-electric hospital bed. Our reviewer says that the requested item is not medically reasonable and necessary. Our physician reviewer found that the documentation does not clearly reveal that your condition has failed positioning of the bed in ways not feasible in an ordinary bed or why positioning of the bed in other ways is not feasible. The documentation does not support a need for frequent or an immediate change in body position or special attachments that cannot be fixed on an ordinary bed. The request for a semi-electric hospital bed is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device (E0673), provided on February 5, 2021.
You asked the Plan to pay for pneumatic compression device. You say that the item was medically necessary. The Plan denied your request. The Plan says the enrollee used the equipment in the facility during and/or after surgery.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that pneumatic compression device was used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0673), provided on February 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient office visit services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve outpatient office visit services. You say that it is medically necessary for you to receive this care from an OON provider. The Plan denied your request. The Plan says they have in-network providers available to provide for your care needs.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve outpatient office visit services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted magnetic resonance procedure coded 72197 provided on January 19, 2021.
You asked the Plan to pay for the unlisted magnetic resonance procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 72197 is unlisted magnetic resonance procedure (eg, diagnostic, interventional). We find that CPT code 72197 is not supported in the medical record. Specifically, the documentation shows that these services are the computer aided evaluation of the magnetic resonance imaging. All services integral to accomplishing a procedure are considered bundled into that procedure and are not separately billed. The Medicare rules say that packaged services are items and services are considered to be an integral part of another service. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the unlisted magnetic resonance procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted magnetic resonance procedure coded 72197 provided on January 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing coded 81404, 81403, 81402, 81400, 81321, 81318, 81314, 81310, 81309, and 81311 provided on May 16, 2021.

You asked the Plan to pay for the Guardant360 testing. 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 81404, 81403, 81402, 81400, 81321, 81318, 81314, 81310, 81309, and 81311 are not supported in the medical record. Specifically, this service should be billed with code 81479. This service was billed with a panel of codes. This means that this service was incorrectly billed. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met.

Therefore, we decided that the Plan does not have to pay for the Guardant360 testing coded 81404, 81403, 81402, 81400, 81321, 81318, 81314, 81310, 81309, and 81311 provided on May 16, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology (88305) rendered by the out-of-network (OON) provider on April 27, 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 surgical pathology (88305) rendered by the out-of-network (OON) provider on April 27, 2021.