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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you are unable to return home. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states your records do not show that you require daily skilled services that can only be provided on an inpatient basis. The Plan states the services you require, such as additional therapy services, can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 required daily skilled services cannot be justified on an inpatient basis. The additional treatment services can be safely received in non-inpatient settings and can be closely coordinated with home health care services. There is no medical necessity for continuous specialized inpatient skill based on the review of the case. The Medicare criteria for SNF has four conditions and all of them must be fully satisfied to be eligible for inpatient SNF. You do not meet the criteria for daily skilled inpatient SNF as per the Medicare guidelines which requires you to meet all the four criteria. Putting you into inpatient SNF can potentially risk your health by exposing you to futile medical care and risk of inpatient infections.  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 skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for 4KScore testing provided on July 8, 2021.  You asked the Plan to pay for 4KScore testing. You say that this test provides a safe and validated strategy to reduce the number of biopsies while evaluating higher-risk individuals for further treatment. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because this test is not covered by Medicare.  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.  This testing was ordered by an in-network physician. The file does not show that the plan provided notice that 4KScore testing would not be covered. The Plan says that 4KScore testing is excluded from Medicare coverage; however, 4KScore testing is covered by Medicare. Under Medicare rules, this means 4KScore testing is considered approved by the plan. Therefore, we decided that the Plan has to pay for 4KScore testing 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shipping costs (A9270), and sales tax (S9999), provided on March 1, 2021, through March 12, 2021.  You asked the Plan to pay for the shipping costs and sales tax. You say that the service should be covered. The Plan denied your request. The Plan says sales tax and shipping costs are not covered benefits.  The Plan must follow Medicare rules. Medicare rules say that Medicare does not reimburse separately for sales tax.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the shipping costs and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for the shipping costs (A9270), and sales tax (S9999), provided on March 1, 2021, through March 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective right shoulder arthroplasty.  You asked the Plan to pay for acute inpatient hospital care associated with an elective surgery. You say that you would like an inpatient admission covered. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care associated with an elective surgery.  Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the elective right shoulder surgery was approved by the Plan. The enrollee is clinically stable and has no acute hemodynamic compromise. The comorbid conditions are clinically stable. The clinical notes do not justify any need for inpatient admission.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care associated with an elective surgery have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care associated with an elective right shoulder arthroplasty.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 We decided that the Plan has to reduce the cost-sharing charges for cardiac catheterization. We decided that the Plan does not have to reduce the cost-sharing charges for Medicare Part B drugs.   You asked the Plan to reduce the cost-sharing charges for cardiac catheterization and Medicare Part B drugs. You say that you feel that the charges are way too high and disagree with the out-of-network cost-sharing charges. The Plan says that the claims were processed correctly and you are being charged the correct amount.  We decided that the Plan has to reduce the cost-sharing charges for cardiac catheterization from $4,595.60 to $250.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities.   The record shows that you received cardiac catheterization on July 23, 2021, at an outpatient hospital facility. Cardiac catheterization is considered an outpatient surgical procedure. Therefore, you cannot be asked to pay more than the $250 copayment.   The plan says that you must pay $4,595.60 for cardiac catheterization. However, you cannot be asked to pay more than a $250 copayment for outpatient surgical procedures. Therefore, we decided that the Plan has to reduce the cost-sharing charges for cardiac catheterization from $4,595.60 to $250.   We also decided that the Plan does not have to reduce the cost-sharing charges for Medicare Part B drugs.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs.  The total allowed amount for Medicare Part B drugs is $160.65 and 20% of that is $32.13. Therefore, we decided that the Plan does not have to reduce the cost-sharing charges for Medicare Part B drugs.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).  You asked the Plan to pre-approve Vertiflex. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex 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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show its safety and efficacy.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interlaminar stabilization device (Vertiflex).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (80048, 80076, 81000) provided on May 29, 2020.  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 the services were non-emergent and not pre-authorized. There were network providers available.    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 services 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 these services. Therefore, we decided that the Plan does not have to pay for lab services (80048, 80076, 81000) provided on May 29, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on February 4, 2020.  You asked the Plan to pay for the pneumatic compression device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has been billed with an invalid modifier.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code E0675 NU KH is not supported in the record. Specifically, the pneumatic compression device at issue is a capped rental item. This claim was billed with the NU modifier indicating this is a new, purchased item. Based on this information, we decided that Medicare rules for coverage of the pneumatic compression device have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on February 4, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81404, 81401, 81403) provided July 1, 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 these tests were for screening purposes and are non-covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (81404, 81401, 81403) provided July 1, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  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 there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.  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 skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiology services (75716) provided April 19, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is inclusive to the primary procedure performed and is not separately payable.  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 75716 is a column II code to column I code 37227. 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 radiology services (75716) provided April 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (S1015, S8301) provided on May 13, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable.  The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes.   We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S1015, S8301) provided on May 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that it is not safe for the enrollee to go home. You state their wife is wheelchair bound and the enrollee needs help in an out of bed. You state the enrollee is no longer tolerating therapy. The Plan denied your request. The Plan says the stay is not medically necessary. The Plan states your request does not meet Medicare guidelines because the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan states all the services the enrollee needs are offered at the IRF and transfer to a SNF for inpatient skilled rehab services is not medically necessary.  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 enrollee has stabilized medically and has been receiving skilled rehabilitation services in an IRF. The enrollee has tolerated inpatient rehabilitation services and continues to improve with daily skilled nursing and/or skilled therapy services. The enrollee could benefit from continued services at the current level of care.  The enrollee has made slow progress with therapy, there is no indication that transfer to a SNF is required. The enrollee can continue to receive skilled rehabilitation services at the current IRF or be stepped down to a lower level of care when appropriate. There are no services offered at a SNF that are not offered at an inpatient rehabilitation facility. Admission to a SNF for inpatient skilled rehabilitation services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pre-approve the Caris Molecular Intelligence (MI) panel.  You asked the Plan to pre-approve the Caris MI panel. You say that this is medically necessary to allow for further treatment and to determine eligibility for future clinical trials. The Plan denied your request. The Plan says that this is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the Caris MI panel. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a male with metastatic adenocarcinoma of the prostate. It is noted that the enrollee may benefit from tumor tissue next-gene sequencing for targeted therapy approved, immunotherapy, and available clinical trials in the future.   The documentation supports that the enrollee in this case has relapsed, metastatic cancer, has not been previously tested with the same test using NGS for the same cancer genetic content, and has decided to seek further cancer treatment such as therapeutic chemotherapy.  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 Caris MI panel have been met. Therefore, we decided that the Plan has to pre-approve the Caris Molecular Intelligence (MI) panel.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a residual limb volume management and moisture evacuation system described by code L5781.  You asked the Plan to pre-approve the vacuum pump volume management/evacuation system. You say that it is felt that these components should be approved. The Plan denied your request. The Plan says two of the components were approved on appeal. However, code L5781 is not considered 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 pre-approve the vacuum pump volume management/evacuation system. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the physician documentation does not support the need for this device. The documentation does not reveal physical exam findings on the physician medical progress notes or a discussion of a medical need for this device on the treating physician progress notes. As such, this request 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 the vacuum pump volume management/evacuation system have not been met. Therefore, we decided that the Plan does not have to pre-approve a residual limb volume management and moisture evacuation system described by code L5781.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computer assisted surgical navigational procedure (20985).  You asked the Plan to pre-approve a computer assisted surgical navigational procedure (20985). You say that the requested computer assisted surgical navigational procedure (20985) is medically necessary. The Plan denied your request. The Plan says the requested computer assisted surgical navigational procedure (20985) 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 pre-approve a computer assisted surgical navigational procedure (20985). Our reviewer says that the requested computer assisted surgical navigational procedure (20985) is not medically necessary. Our physician reviewer found computer navigation is not medically needed. Published literature shows that computer navigation is not more clinically effective than conventional surgery.  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 computer assisted surgical navigational procedure (20985) have not been met. Therefore, we decided that the Plan does not have to pre-approve a computer assisted surgical navigational procedure (20985).