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 requested admission is medically necessary. The Plan denied your request. The Plan says the requested IRF admission is not medically necessary.  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 provided documentation indicates that the enrollee's medical condition is stable and does not have complex nursing or rehabilitation needs. The reviewer found that there is no documentation of a need for an intensive rehabilitation program. The reviewer also found that 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. Therefore, the reviewer found that the IRF admission 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 IRF care have not been met. Specifically, the file shows that the enrollee does not have a need for an intensive rehabilitation program. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gel-One.  You asked the Plan to pre-approve Gel-One. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Gel-One. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has pain related to osteoarthritis of the right knee, diagnosis confirmed with imaging studies. The enrollee has tried cortisone injections to the knee. The documentation does not support that the enrollee has tried Euflexxa and either Durolane, Gelsyn-3, or SupartzFX. The documentation does not support an indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 30, 2021.  You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the services were not billed as required.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    The file shows that antibody testing and a hepatic function panel were provided. We looked at the file and the rules. In this case, we find that the testing at issue is not supported in the medical records. The records do not indicate the testing was ordered due to signs and symptoms the enrollee was experiencing. The records do not show that the results of the testing would be used in the management of specific medical problems. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on March 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.

You asked the Plan to pre-approve BRCA genetic testing. You say that this testing should be covered due to your family history of ovarian cancer. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because this testing is not medically necessary for you.

The Plan follows Medicare rules. Medicare rules state that BRCA genetic testing may be covered for enrollees with a current diagnosis or personal history of certain cancers that meet criteria in current guidelines. 

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 BRCA genetic testing. Our reviewer says that you do not meet the Medicare criteria for BRCA genetic testing. Our physician reviewer found the record does not indicate that you have a current or personal history of breast cancer. Therefore, the requested testing is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BRCA genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve BRCA1 and BRCA2 genetic testing.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on April 19, 2021.

You asked the Plan to pay for the ConfirmMDx testing. You say that you would like reconsideration because this testing is a Medicare covered benefit. The Plan denied your request. The Plan says this testing was not medically necessary.

The Plan follows Medicare rules. Medicare rules say that ConfirmMDx is covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 

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 ConfirmMDx testing. Our reviewer says that based on the medical records provided there is no documentation that the ConfirmMDx Epigenetic Molecular Assay in this case meets Medicare criteria for coverage. Our physician reviewer found the records do not document a previous cancer-negative prostate biopsy within 24 months and the enrollee is being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. 

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 ConfirmMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided on July 23, 2021.  You asked the Plan to pay for the ultrasonic guidance for needle placement. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the supporting documentation submitted did not warrant the additional reimbursement sought for CPT code 76942.  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 ultrasonic guidance for needle placement. Our reviewer says that the documentation did not support that an additional unit of CPT code 76842 was 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 the ultrasonic guidance for needle placement have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasonic guidance for needle placement (76942) provided on July 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) scan of the head and neck.  You asked the Plan to pre-approve MRA services. You say that this imaging service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage for the requested MRA have not been met.  The Plan follows Medicare rules. Medicare rules say that an MRA scan of the head and neck are subject to the criteria listed 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 MRA services. Our reviewer says that the requested imaging services are not medically reasonable and necessary. Our physician reviewer found based on the medical records provided there is no documentation that the requested magnetic resonance angiogram of the neck meets Medicare criteria for medically reasonable and necessary. Records do not document tumor, aneurysms, vascular malformations, vascular occlusion or thrombosis or other pathology of the blood vessels of the neck including the carotid arteries or the vertebral arteries.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of MRA services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance angiography (MRA) scan of the head and neck.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 2, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99214) rendered by the out-of-network (OON) provider on August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laparoscopy services (49322) billed with the -59 modifier provided on May 19, 2021.  You asked the Plan to pay for the laparoscopy services. You say that medical records collaborate the billed code. The Plan denied your request. The Plan says the documentation provided does not support the claim 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. The rules also state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.    In this case, the CPT Code Manual definition of code 49322 is laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple).  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 laparoscopy services. Our reviewer says that the code as billed is not supported by the documentation provided. Our reviewer found CPT 49322-59 is inclusive to CPT 44970 which was performed on March 19, 2021 and the medical records do not include sufficient documentation that 49322 was performed as a distinct/ separate service, therefore, no additional reimbursement is allowed.  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 laparoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the laparoscopy services (49322) billed with the -59 modifier provided on May 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OsteoCel Allograft (CPT code 20930), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee is in extreme pain that cannot be managed without the requested treatment. The Plan denied your request. The Plan says the clinical value and effectiveness of the OsteoCel Allograft in the setting of a lumbar spine fusion surgery have not been demonstrated in the peer-reviewed literature.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Osteocell allograft is experimental in spinal surgery. More research is needed to show safety and efficacy of the allgraft material.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve OsteoCel Allograft (CPT code 20930), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services (G0483) provided to the enrollee on January 19, 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 the records do not support the services billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."  We find that CPT code G0483 is not supported in the medical record. Specifically. 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 drug testing services (G0483) provided to the enrollee on January 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Grafix prime and grafixpl prime provided to the enrollee on September 2, 2021.  You asked the Plan to pay for these items. You say that these items were medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of skin graft, Grafix prime and grafixpl prime in the setting of a surgical wound have not been demonstrated in the peer-reviewed literature.  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 these items. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. The enrollee underwent a procedure on September 2, 2021 for excision of a right leg cutaneous basal cell carcinoma. The repair was by complex closure and application of Grafix graft. Per the reviewed literature Grafix prime is indicated for the treatment of neuropathic diabetic foot ulcers that are greater than six weeks old in duration and is used in conjunction with standard diabetic ulcer care. The clinical value and effectiveness in the setting of surgical wounds has not been demonstrated. There is no documentation indicating that the wound has failed to respond to standard wound care. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these items.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these items have not been met. Therefore, we decided that the Plan does not have to pay for the Grafix prime and grafixpl prime provided to the enrollee on September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services (11042, 29581, 99213) provided on June 24, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the podiatry services. You say that the care provided was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON provider.

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 podiatry services (11042, 29581, 99213) provided on June 24, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the discharge day management services provided on February 10, 2021.

You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed code 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 CPT code.

In this case, the CPT Code Manual definition of code 99316 is nursing facility discharge day management; more than 30 minutes. We find that CPT code 99316 is not supported in the medical record. Specifically, the records do not indicate the amount of time spent with the enrollee for the discharge management. 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 discharge day management services provided on February 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan provided to the enrollee on July 7, 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 a corrected claim is needed.

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 71271 is "Computed tomography, thorax, low dose for lung cancer screening, without contrast material(s)." 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation supports a place of service 22 (on campus/outpatient hospital). Therefore, modifier 26 professional component should be appended to this procedure. A physician who performs the interpretation of an x-ray exam in the hospital outpatient setting may submit a charge for the professional component of the x-ray service using a modifier 26 appended to the x-ray code. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan provided to the enrollee on July 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Spineology OptiMesh cage (CPT code 22853 x2), for the enrollee.  You asked the Plan to pre-approve the service. You say that the enrollee is having problems walking and is having weakness in their legs. You state this service is medically necessary. The Plan denied your request. The Plan says the clinical value and effectiveness of OptiMesh cage in the setting of spine fusion surgery have not been demonstrated in the peer-reviewed literature.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Optimesh cage remains experimental. More research is needed to show safety and efficacy of the device.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve Spineology OptiMesh cage (CPT code 22853 x2), for the enrollee.