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

 We decided that the Plan does not have to pay for the allograft, morselized, or placement of osteopromotive material, for spine surgery only (CPT code 20930) provided to the enrollee on July 16, 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 covered 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. In this case, we have confirmed that code 20930, has a status indicator of 'B' on the CMS Physician Relative Value File, and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 the allograft, morselized, or placement of osteopromotive material, for spine surgery only (CPT code 20930) provided to the enrollee on July 16, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.     We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion/specialty drug administration, per visit (CPT code(s): 99601 and 99602) provided to the enrollee on March 25, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. 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. Providers must report services with the appropriate CPT code. 

Both CPT code(s): 99601 and 99602 have a status code of "I". Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 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 home infusion/specialty drug administration, per visit (CPT code(s): 99601 and 99602) provided to the enrollee on March 25, 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the medical records provided 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. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is no documentation that the enrollee requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation 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 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 periodontal scaling and root planing (D4341) provided on June 10, 2021 and June 24, 2021.

You asked the Plan to pay for periodontal scaling and root planing (D4341). You say that you assumed this was preventive. The Plan denied your request. The Plan says the service is not a covered benefit.

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 periodontal scaling and root planing (D4341) provided on June 10, 2021 and June 24, 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 will regain benefits from rehabilitation in an IRF and be able to return to a normal level of function. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.  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 that 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. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay an additional amount for the inpatient hospital care provided from May 27, 2021, to May 29, 2021.

You asked the Plan to pay an additional amount for the inpatient care. You say that you are being balance billed by a plan provider. The Plan denied your request. The Plan says that this claim paid at 100 percent of the appropriate allowable charges. 

The Plan also says they will continue to communicate with the provider at issue to advocate this position on your behalf.
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. 

You were referred for the inpatient care by a contract provider. The file does not show that the Plan provided notice that the inpatient care would not be covered. Under Medicare rules, this means the inpatient care is considered approved by the Plan. Additionally, the file does not show that the Plan has confirmed that the provider has written off these charges. Therefore, we decided that the Plan has to pay an additional amount for the inpatient hospital care provided from May 27, 2021, to May 29, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeomin (incobotulinumtoxinA) injections.

You asked the Plan to pre-approve the Xeomin injections. You say that this should be allowed. The Plan denied your request. The Plan says the clinical value and effectiveness of Xeomin injection in the setting of vertigo, cervical musculature pain and/ or vertiginous migraines have not been demonstrated in the peer-reviewed literature.

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 the Xeomin injections. Our reviewer says that the requested type of injection is not considered reasonable and necessary. Our physician reviewer found the enrollee is a male who has symptoms of vertigo and syncope secondary to cervical musculature. The clinical value and effectiveness of Xeomin injection in the setting of vertigo, cervical musculature pain and/or vertiginous migraines have not been demonstrated in the peer-reviewed 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 the Xeomin injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Xeomin (incobotulinumtoxinA) injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.  

You asked the Plan to pre-approve Vertiflex. You say that this is highly recommended as a safer alternative to a laminectomy or spinal fusion. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is considered unproven and lacking evidence.  

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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its safety and efficacy.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on January 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 covered 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. In this case, we have confirmed that code 99100, has a status indicator of 'B' on the CMS Physician Relative Value File, and is always bundled into payment for other services not specified and no separate payment is made per Medicare. 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 anesthesia for patient of extreme age, younger than 1 year and older than 70 (CPT code 99100) provided to the enrollee on January 7, 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 LTACH admission is medically necessary. The Plan denied your request. The Plan says the requested LTACH admission is not medically necessary.

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 admission is not medically necessary. Our physician reviewer found there is no documentation provided indicating medical necessity for LTACH services. 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 at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intraperitoneal nutrition (IPN) therapy.  You asked the Plan to pre-approve intraperitoneal nutrition (IPN) therapy. You say that the requested intraperitoneal nutrition (IPN) therapy is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for intraperitoneal nutrition (IPN) therapy.  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 intraperitoneal nutrition (IPN) therapy. Our reviewer says that the enrollee does not meet criteria for intraperitoneal nutrition (IPN) therapy. Our physician reviewer found the enrollee does not meet criteria for intraperitoneal nutrition (IPN) therapy.  The enrollee does not have malabsorptive disorder. It is not unusual for peritoneal dialysis patients to have albumin of 3.4 due to the process and the process can cause net loss of protein.  I did not see further signs of malnutrition such as weight loss mentioned. The records provided have not demonstrated criteria that would qualify for IPN.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intraperitoneal nutrition (IPN) therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve intraperitoneal nutrition (IPN) therapy.
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 records provided support the need for care in an IRF. You say that you have not been able to walk since having a stroke in January of 2020. You say that you want to go to an IRF for 3-4 hours of daily rehabilitation so you can walk again and take care of yourself. The Plan denied your request. The Plan says the enrollee does not need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehabilitation.  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 enrollee is medically stable and does not meet Medicare coverage criteria for an IRF admission. With her current medical stability, and no other medical complexity, there is no need for physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. She has no acute rehabilitation nursing needs. At the current functional level, she does not require intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. There is a discrepancy in the documentation of her functional status. The enrollee will not be able to make significant functional gains in the predicted period of time in an IRF based on physical therapy evaluation on December 17, 2021. IRF admission is not medically necessary based on medical stability and lack of acute nursing needs. Documentation does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical therapy and occupational therapy, her rehabilitation needs can be safely met in an alternate and low intensity setting such as in a skilled nursing facility or continuation of therapies at 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 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June 22, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the domiciliary or rest home visit. You say that it is the nursing facilities responsibility to get authorizations for their patients. You did not know that the facility failed to get pre-authorization so you treated this enrollee anyways. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) provided on June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on May 27, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  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 drug testing have not been met. CPT code G0483 - 90 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided to the enrollee on May 27, 2021.