Persius/hicric huggingface dataset:
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 SNF care. You say that SNF care is medically reasonable and necessary. The Plan denied your request. The Plan says the rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a 78-year-old female with left lower extremity cellulitis. While there are identifiable skilled nursing service needs, there are no identifiable skilled therapy service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Push Injection 420/3.5 (CPT code J3590), for
the enrollee.
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied
your request. The Plan says the medication does not fall under Part B coverage. The Plan states the enrollee does not have pharmacy (drug) benefits administered by this health plan. The Plan
states the enrollee does have pharmacy benefits through another pharmacy vendor.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Repatha Push Injection
420/3.5 (CPT code J3590), for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (99214 and 90833) provided on
May 20, 2021, through June 4, 2021.

You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because
this is the only provider in your area who can treat your condition. The Plan denied your request. The Plan says
these services were rendered by a provider who is not under contract with the health plan and is not certified
for Medicare.

The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.

The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the
psychotherapy services (99214 and 90833) provided on May 20, 2021, through June 4, 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 need IRF care. The Plan denied your request. The Plan says rules for IRF care 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 that you were admitted for coronary artery bypass grafting. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation for the enrollee.
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 information fails to indicate at least medial branch blocks with at least 80% pain
relief.
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 the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no documentation of the degree or duration of the pain relief achieved. Therefore, the request
and the previous procedures should be considered medically unreasonable and unnecessary. It is below the
standard of care not to document the degree and duration of pain relief.
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 radiofrequency ablation for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D2710) provided August 10, 2021.
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the dental benefit was exhausted at the time the services were provided.
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 enrollee's $5,000 benefit was
exhausted at the time the services were rendered. Therefore, we decided that the Plan does not have to pay for
dental services (D2710) provided August 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76942) provided April 30, 2021.
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan
denied your request. The Plan says payment for this service is bundled with another service.
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 76942
shares a bundled relationship with code 36561. 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 an ultrasound (76942) provided April 30, 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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear you would be able to fully benefit and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve Botox. You say that the medication is 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 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 Botox. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the Botox is medically reasonable and necessary for the enrollee. The documentation does not support that the Botox is safe and effective for 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 Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat lumbar epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this would be the sixteenth (16th) epidural steroid injection at this site.
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 the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found as the enrollee has not had an imaging study of the L5-S1 region to rule out other etiologies of the member pain, the request for a repeat epidural steroid injection cannot be approved as reasonable and necessary. Furthermore, this would be the sixteenth (16th) epidural steroid injection at this site. Consideration of radiographs to rule out other etiologies, consideration of more definitive treatment, and other management modalities could be considered as an alternative. The review has determined that the enrollee does not meet the criteria for a repeat injection.
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 injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a repeat lumbar epidural steroid injection for the enrollee
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate (20939).

You asked the Plan to pre-approve bone marrow aspirate. You say that this is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested procedure is
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 bone marrow aspirate. Our reviewer
says that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found bone marrow aspirate remains experimental for use in spinal surgery. More research
is needed to show safety and efficacy when used as bone graft.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan
does not have to pre-approve bone marrow aspirate (20939).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0012M) provided May 3, 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 this service is non-covered under Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that code 0012M for CxBladder is non-covered. We looked at the file and Medicare rules. The lab testing at issue is not covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (0012M) provided May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Mycophenolic acid.
You asked the Plan to pre-approve a tier exception for Mycophenolic acid. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Mycophenolic acid have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Mycophenolic acid
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cxbladder testing rendered on April 28, 2021.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on April 28, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge management (99239) provided October
20, 2020.
You asked the Plan to pay for the hospital discharge management services. You say that the services were
medically necessary. The Plan denied your request. The Plan says the documentation does not support the
billed services.
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 code 99239 is not supported in the medical record. Specifically, a duration of 31 minutes or
more is needed to support the billed code. The records do not document how much time was spent on this
service. Based on this information, we decided that Medicare rules for coverage of the hospital discharge
management services have not been met. Therefore, we decided that the Plan does not have to pay for hospital
discharge management (99239) provided October 20, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care 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 the patient was admitted for a fall, respiratory failure, coronavirus pneumonia, atrial fibrillation, and Non-ST-elevation myocardial infarction. Medical problems are stable. There are no complex
nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an evaluation and dental extraction of tooth #29 to be performed by an oral surgeon.

You asked the Plan to pre-approve an evaluation and dental extraction of tooth #29 to be performed by an oral surgeon. 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.

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. The Plan says covered services must be performed by a participating general dentist. 

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an evaluation and dental extraction of tooth #29 to be performed by an oral surgeon have not been met. Therefore, we decided that the Plan does not have to pre-approve an evaluation and dental extraction of tooth #29 to be performed by an oral surgeon.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home health aide services.

You asked the Plan to pre-approve the home health aide services. You say that these services are medically necessary for your condition. The Plan denied your request. The Plan says supporting documentation to corroborate the need for these services was not provided.

The Plan must follow Medicare rules. The rules say that an enrollee must be homebound for home health care services to be covered. The rules also 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. 

The file does not show that you are homebound. Specifically, the Plan made several requests to your provider for additional records to support your homebound status and need for medical services, but no documentation was received. Without this documentation, we are unable to determine the medical necessity of the requested home health aide services. Therefore, we decided that the Plan does not have to pre-approve the home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve the CGM. You say that the enrollee needs the CGM as she cannot use lancets. The Plan denied your request. The Plan says the criteria are not met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) rendered on July 23, 2021.
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 code 43262 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 43262 (ERCP) and 43274 (ERCP with sphincterotomy/papillotomy). Code 43262is a column II code with a modifier indicator of 1 when billed with
column I code 43274. Code 43262 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the endoscopic retrograde cholangiopancreatography (ERCP) rendered on July 23, 2021.