Persius/hicric huggingface dataset:
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 enrollee requires inpatient rehabilitation services. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can receive skilled therapies in an alternate setting.  

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 based on the enrollee's current medical stability, and no other medical complexity, there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute rehab nursing needs. At her current functional level, the enrollee 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. She will not make a significant functional recovery in the predicted 7-10 days in IRF at the current max A level. It is unrealistic to expect her to meet the goals outlined in the preadmission screen. Documentation does not support the necessity for admission to IRF. While the enrollee may benefit from continued physical and occupational therapies, her rehab 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve L2 kyphoplasty with placement of bone cement spacer surgery 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 enrollee is beyond the acute and subacute timeframe for this procedure to be performed.  

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 the medical records do not show that the fracture is less than twelve weeks old. The criteria is not met.  

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 L2 kyphoplasty with placement of bone cement spacer surgery for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for out of network physician services provided to the enrollee from February 22, 2021, to July 27, 2021.  

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 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 out of network physician services provided to the enrollee from February 22, 2021, to July 27, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for drugs unclassified injection (J3490) provided on April 7, 2021.

You asked the Plan to pay for drugs unclassified injection (J3490). The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged. 

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. 

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for drugs unclassified injection (J3490) provided on
April 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on July 22, 2021.  

You asked the Plan to pay for the services provided. You say that the claim should be paid. The Plan denied your request. The Plan says separate payment is not allowed.  

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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. Payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on July 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on April 12, 2021.

You asked the Plan to pay for the lab services. You say that the testing performed can affect clinical decisions. The Plan denied your request. The Plan says the billed codes cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.

We looked at the file and the rules. In this case, the claim provided lists a place of service as an independent laboratory. The records provided do not substantiate the specimen was obtained at an independent laboratory. 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 the lab services provided on April 12, 2021.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for genetic testing provided on April 22, 2021.

You asked the Plan to pay for genetic testing. You say that you are the sole provider of this testing and this testing meets Medicare coverage criteria. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because prior authorization was not obtained.

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 April 22, 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: Favorable

 We decided that the Plan has to pre-approve Durvalumab 10mg 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 that there is no evidence of stage III disease, or lymph node-positive disease.  

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 injection. Our reviewer says that the requested injection is medically reasonable and necessary. Our physician reviewer found the enrollee has inoperable stage II non-small-cell lung cancer (NSCLC) being treated as stage III NSCLC having completed chemotherapy radiation. Durvalumab would be standard for maintenance therapy. The service is reasonable and 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 the injection have been met. Therefore, we decided that the Plan has to pre-approve Durvalumab 10mg injection for the enrollee.   

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 genetic testing (0012M) provided July 12, 2021.  

You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is non-covered.  

The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for CPT code 0012M.  

We looked at the file and Medicare rules. The test performed is non-covered. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0012M) provided July 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the insertion of a temporary indwelling bladder catheter (51702), the home visits for the evaluation and management of an established patient (99348, 99349), and the routine venipuncture (36415) rendered by the out-of-network (OON) provider from April 14, 2021, through June 24, 2021.  

You asked the Plan to pay for the services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the insertion of a temporary indwelling bladder catheter (51702), the home visits for the evaluation and management of an established patient (99348, 99349), and the routine venipuncture (36415) rendered by the out-of-network (OON) provider from April 14, 2021, through June 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for an automatic external defibrillator vest (K0606) provided on April 25, 2021, by an out-of-network provider.  

You asked the Plan to pay for an automatic external defibrillator vest. You say that the Plan's prior authorization process is opaque. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  

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 an automatic external defibrillator vest (K0606) provided on April 25, 2021, by an out-of-network provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve myocardial imaging, positron emission tomography (PET) scan (78431).  

You asked the Plan to pre-approve a PET scan. You say that this testing is medically necessary. The Plan denied your request. The Plan says there was no past treadmill test or previous negative or non-diagnostic treadmill test in the setting of an ongoing typical angina. There was no inability to ambulate on a treadmill. In the setting of this case, the addition of a PET scan to the standard treadmill testing has not been established as standard of care toward improved cardiac outcomes. There is no documentation that the requested PET scan is medically necessary at this time.  

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 a PET scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee presented with a history of CAD, risk factors, and cardiac asymptomatic prior to an intermediate risk surgery. There were no baseline ECG abnormalities that would preclude accurate interpretation during treadmill testing such as a left bundle branch block, paced rhythm, digoxin therapy, pre-excitation, 1mm or greater baseline ST depression, or atrial fibrillation/flutter. There was also no past submaximal treadmill test, or previous negative or non-diagnostic treadmill test, in the setting of ongoing typical angina. There was no inability to ambulate on a treadmill. In the setting of this case, the addition of imaging, such as CT/SPECT, to standarew has determined that the requested nuclear stress testing/PET scan 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial imaging, positron emission tomography (PET) scan (78431).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88342-TC, 88341-TC, 88360-TC) provided on January 8, 2021 .

You asked the Plan to pay for laboratory services. You say that this was billed correctly. The Plan denied your request. The Plan says this cannot be paid with the billed modifier.

The Plan must follow Medicare rules. Medicare rules say that only the hospital may bill for the TC of a physician pathology service provided to an inpatient or outpatient. 

We looked at the file and Medicare rules. The services at issue were billed with the TC modifier to indicate the technical component, and the records show that they were provided while the enrollee was an inpatient. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88342-TC, 88341-TC, 88360-TC) provided on January 8, 2021
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for realignment of extensor tendon, hand, each tendon provided on August 13, 2021.  You asked the Plan to pay for tendon realignment. You say that the coding is correct and modifier -XU is in place to override being inclusive to 26531. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these codes are inclusive to code 26531 and no acceptable modifier has been approved to bypass this.  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 26437-XU-F1, -F2, -F3, and -F4 is realignment of extensor tendon, hand, each tendon for left hand second, third, fourth, and fifth digits.  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 tendon realignment.  Our reviewer says that these codes do not meet the criteria for payment. Our reviewer found code 26437 is inclusive to code 26531. A modifier is allowed to unbundle these services provided the records support the use of the modifier. The records do not include sufficient documentation to support unbundling these services from procedure 26531.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tendon realignment have not been met. Therefore, we decided that the Plan does not have to pay for realignment of extensor tendon, hand, each tendon provided on August 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for Hako-Med bioelectric therapy and FDA Nutri-Pharmaceutical blend provided to the enrollee on June 8, 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 services that are considered to be experimental or investigational are excluded from coverage.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the use of electrostimulation/electromagnetic stimulation alone for neuropathies or peripheral neuropathies caused by underlying systemic diseases, is insufficient to warrant coverage. These procedures are considered investigational and are not eligible for coverage for the treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases. Regarding  the subcutaneous injection of FDA Nutri-Pharmaceutical blend, the clinical value and effectiveness of the non-antineoplastic hormonal injections, FDA Nutri-Pharmaceutical blend in the setting of chronic pain and paresthesia have not been demonstrated in the 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 services have not been met. Therefore, we decided that the Plan does not have to pay for Hako-Med bioelectric therapy and FDA Nutri-Pharmaceutical blend provided to the enrollee on June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for prolotherapy, transcutaneous electrical nerve stimulation (TENS), and a pneumatic/vasopneumatic device provided to the enrollee on June 7, 2021.

You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.

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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the provided documentation, there is insufficient support made for meeting criteria for the requested treatments The prolotherapy does not have sufficient current and high quality evidence to support its use in the setting of this enrollee's condition.

The TENS was not documented as having been tried and successful in the office setting to support regular use and is also not covered by Medicare. The pneumatic device is only supported for venous insufficiency/stasis ulcers, and refractory lymphedema which this enrollee does not have, according to the records provided. Therefore, the items and services requested will be considered 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy, transcutaneous electrical nerve stimulation (TENS), and a pneumatic/vasopneumatic device provided to the enrollee on June 7, 2021.