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

 We decided that the Plan has to pre-approve Oncotype MAP PanCancer testing.  You asked the Plan to pre-approve Oncotype MAP PanCancer testing. You say that you are appealing this denial. The Plan denied your request. The Plan says that the denial of authorization for this testing is correct, because this panel testing includes several tests that are not related to your cancer and is not Food & Drug Administration (FDA) approved.  The Plan follows Medicare rules. Medicare rules state that next generation sequencing testing may be covered under certain circumstances.  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 Oncotype MAP PanCancer testing. Our reviewer says that you meet the Medicare criteria for this Oncotype MAP PanCancer testing. Our physician reviewer found you have recurrent lung cancer and have not received prior systemic therapy. Guidelines recommend next generation sequencing as a standard of care to guide therapeutic decision-making. A specific brand or type of panel is not specified. The use of Oncotype MAP PanCancer tissue for next generation sequencing is medically reasonable and 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 Oncotype MAP PanCancer testing have been met. Therefore, we decided that the Plan has to pre-approve Oncotype MAP PanCancer testing.   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 May 18, 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. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 18, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast (77047).  You asked the Plan to pre-approve MRI services. You say that these MRI services are medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  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 services. Our reviewer says that the requested MRI services are not medically reasonable and necessary. Our physician reviewer found the patient is a 73-year-old female status post bilateral mastectomy and reconstruction in 2002 following breast cancer diagnosis. Breast MRI was requested. Mammogram from 2021 did not show suspicious or inconclusive findings. The documentation did not reveal report of physical abnormalities of the chest or other prior abnormal imaging, or recent positive biopsy result to justify follow-up with MRI at this time. Therefore, without sufficient support made, the MRI will be considered not medically necessary at this time.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRI services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the breast (77047).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).  You asked the Plan to pre-approve the dentures. You say that you need these dentures The Plan denied your request. The Plan says dentures may only be covered once per arch every 60 months. You previously received a complete lower denture and complete upper denture in January 2019, which were covered by the Plan. Therefore, your benefit for dentures is exhausted at this time.  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 can cover partial or complete dentures once every 60 months per arch.  Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that exceeds what is covered under this benefit. Documentation shows that you previously received a complete upper denture and complete lower denture less than 60 months prior to this request which were covered by the Plan at that time. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
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 these services are medically necessary. The Plan denied your request. The Plan says that records show that there is no need for an intensive rehabilitation program.  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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Your 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. 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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.
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to be held harmless for biopsy services (38525AS) and mastectomy services (19301AS) provided on July 8, 2021.  You asked the Plan to be held harmless for the medical services. You say that you would like these claims reprocessed. The Plan denied your request. The Plan says that the assistant at surgery during these services as not medically reasonable and necessary.  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.  In this case, the services were rendered by a contracted provider. The file does not show that the Plan provided notice that the medical services would not be covered. Under Medicare rules, this means the medical services are considered approved by the Plan. Therefore, we decided that the Plan has to be held harmless for biopsy services (38525AS) and mastectomy services (19301AS) provided on July 8, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 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 at the present setting 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.   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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the implant removal (20680) provided on April 12, 2021.  You asked the Plan to pay for the implant removal. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service is inclusive to CPT code 28740.  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 20680 is removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate).  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 implant removal. Our reviewer says that CPT code 20680 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not include documentation to support that this procedure is not inclusive of CPT 28740.  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 implant removal have not been met. Therefore, we decided that the Plan does not have to pay for the implant removal (20680) provided on April 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).  You asked the Plan to pre-approve additional routine transportation trips. You say that you need transportation to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 trips per year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infectious agent detection with 6-11 targets (87506) provided on April 6, 2021.  You asked the Plan to pay for the infectious agent detection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for the services rendered.  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 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 infectious agent detection. Our reviewer says that CPT code 87506 does not meet criteria for billing or reimbursement consideration. Our reviewer found the laboratory report documents that more than 11 targets were tested, and therefore, a more appropriate code exists and should be reported.  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 infectious agent detection have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection with 6-11 targets (87506) provided on April 6, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay additionally for the skilled nursing facility (SNF) care provided from February 26, 2020 to February 29, 2020.  You asked the Plan to pay additionally for the SNF care. 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.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.  We looked at the file, the Plan's contract and Medicare rules. In this case, the Plan reduced payment for the skilled nursing facility (SNF) care due to the documentation received not supporting all the items in Section GG to calculate the Patient-Driven Payment Model (PDPM) score billed due to the Section GG Admission Assessment form dated February 27, 2020 not being signed by the clinicians who conducted the assessment of the Section GG activities. Therefore, we decided that the Plan does not have to pay additionally for the skilled nursing facility (SNF) care provided from February 26, 2020 to February 29, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the detailed and extensive oral evaluation - problem focused, by report (D0160) provided June 28, 2021.  You asked the Plan to pay for the extensive oral exam. You say that this service was required in order for the dental surgery to be performed. The Plan denied your request. The Plan says this service is not covered under your benefits.  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 the detailed and extensive oral evaluation - problem focused, by report (D0160) provided June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services at a 24-hour facility provided on April 19, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says no separate payment are made for these services per Medicare.  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 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service.  We find that CPT code 99053 is not supported in the medical record. Specifically, under the Physician Fee Schedule this code has a status indicator of "B" to indicate it is a Bundled Code. As a result, payment for these services is always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services at a 24-hour facility provided on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Viberzi.  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 self-administered drugs are not covered.  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 Viberzi.   Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that you have ankle pain and do not want to have surgery. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued care in a skilled nursing facility (SNF).  You asked the Plan to pre-approve ongoing SNF care. You say that the enrollee is not safe to go home at this time and requires ongoing wound care services. The Plan denied your request. The Plan says services in a skilled nursing facility (SNF) are only covered up to 100 days per benefit period. A new benefit period begins on day one of enrollment in a Medicare Advantage Plan or when the enrollee has been discharged from skilled care in an SNF for 60 consecutive days. Medical records show that the enrollee will have used their 100 days during the current benefit period by November 24, 2021.  The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.   The file shows that the enrollee received 100 days of SNF care during the benefit period. The Plan has covered 100 days of SNF care.   Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued care in a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a scooter.  You asked the Plan to pre-approve a scooter. You say that the scooter being requested is necessary due to your heart condition. You say that if you stand for too long you have fallen, and your doctor referred you to get this item. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of the requested item.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 scooter. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support that the enrollee has a mobility limitation that significantly impairs his ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal that the enrollee's reported mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker or manual wheelchair. The documentation does not reveal that the enrollee's home provides adequate access for the requested scooter and that the use of the scooter will significantly improve the enrollee's mobility-related activities of daily living in 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 a scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a scooter.