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

We decided that the Plan does not have to pre-approve Sertraline HCL for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Sertraline HCL for the enrollee.
Benefits for this drug 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan for the enrollee.
You asked the Plan to pre-approve Hyalgan. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee has not tried and failed intraarticular steroid injections, and there is no concern for contraindications or adverse effect for a steroid injection.
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation therapy for the knee can be covered if LCD criteria have been met. 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 Hyalgan. Our reviewer says that Hyalgan is not considered medically reasonable and necessary in this case. There is no documentation provided indicating that the enrollee has tried and failed intra-articular steroid injections, and there is no contraindication or adverse effect for a steroid injection. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for Hyalgan. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional neuropsychological testing services (96133, 96137).
You asked the Plan to pre-approve additional neuropsychological testing services. You say that the requested services are medically reasonable and necessary. The Plan denied your request. The Plan says additional testing services beyond what has been approved is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the requested neuropsychological testing is subject to the criteria listed in the medical records. 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 additional neuropsychological testing services. Our reviewer says that the requested services are not medically reasonable and necessary. Our physician reviewer found there is nothing within the records provided for review that support the provision of additional testing beyond that which has already been approved by the member's health plan. The member does not have any comorbid conditions as defined in the LCD for this service that would support provision of additional testing at this time. The member has no significant neurological or psychological condition that would potentially warrant additional testing. This request would not be 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 additional neuropsychological testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional neuropsychological testing services (96133, 96137)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99244) provided October 22, 2020.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99244 is not supported in the medical record. Specifically, this code has a status of "I" per the National Physician Fee Schedule and is invalid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99244) provided October 22, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you need IRF care. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you were admitted for new onset multiple sclerosis. 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 do have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from December 12, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that continued inpatient psychiatric services are medically necessary for this enrollee. The Plan denied your request. The Plan says as of December 12, 2021, the enrollee does not meet the criteria for continued psychiatric care at the inpatient level. The enrollee can be discharged to a less restrictive level of care. Coverage has been approved from December 7, 2021, to December 11, 2021.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on December 7, 2021 with Major Depressive Disorder, Single Episode, Unspecified and Opioid Use Disorder, Uncomplicated. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The enrollee was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her treatment. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question. Based upon a review of the records provided, the enrollee does not meet the criteria for inpatient psychiatric care from December 12, 2021, forward. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from December 12, 2021, forward.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that you are receiving appropriate in-patient acute care and does not require transfer to LTACH.
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. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. Our physician reviewer found that your condition does not meet Medicare criteria for LTACH services. 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 long term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the breast biopsies (19083 x 2), the placement of breast localization device(s) (19285), the biopsy or excision of lymph node(s) (38525), the bone imaging; whole body (78306), and the computed tomography (CT) scan, of the thorax, diagnostic; with contrast material (71260) provided from March 4, 2021, through May 13, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to the services provided.
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 $300 copayment for each Medicare-covered outpatient hospital facility visit for outpatient surgery. Enrollees must pay the lesser of a 20% coinsurance or a $150 copayment for computed tomography (CT) scans, magnetic resonance imaging (MRI's), and all other nuclear medicine radiological services. Additionally, enrollees must pay a $75 copayment for all other diagnostic radiology services. You have been asked to pay $1,200 ($300 copayment x 4) for the Medicare-covered outpatient hospital facility visits for outpatient surgery provided on March 4, 2021, March 24, 2021, April 5, 2021, and April 7, 2021. Additionally, you have been asked to pay $73.19 (Plan allowed amount of $365.94 x 20% coinsurance) for the bone imaging service provided. You have also been asked to pay $84.45 (Plan allowed amount of $422.23 x 20% coinsurance) for the computed tomography (CT) scan of the thorax provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the breast biopsies (19083 x 2), the placement of breast localization device(s) (19285), the biopsy or excision of lymph node(s) (38525), the bone imaging; whole body (78306), and the computed tomography (CT) scan, of the thorax, diagnostic; with contrast material (71260) provided from March 4, 2021, through May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care in the current facility. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which the LTACH would provide a therapeutic advantage.
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 indicating medical necessity for 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 acute care hospital 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 long term acute care hospital (LTACH) services
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 to an IRF is medically
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet
criteria.
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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for multiplex respiratory pathogen panel testing provided on
August 4, 2021.
You asked the Plan to pay for multiplex panel testing. You say that this testing was approved by the referring
physician. The Plan denied your request. The Plan says this testing is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that respiratory viral panels of 6 or more pathogens
are non-covered.
We looked at the file and Medicare rules. This testing is not covered by Medicare. Based on this information,
we decided that Medicare rules for coverage of multiplex panel testing have not been met. Therefore, we
decided that the Plan does not have to pay for multiplex respiratory pathogen panel testing provided on August
4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87340, 80061, 84450, 83615) provided March
3, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the claim cannot be paid 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.
We find that CPT code 87340, 80061, 84450, & 83615 is not supported in the medical record. Specifically, the
claim was not submitted with a valid diagnosis code. Based on this information, we decided that Medicare rules
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for
lab services (87340, 80061, 84450, 83615) provided March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on July 27,
2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services are not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography
angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with
column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment.
Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan rendered on
July 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the
out-of-network (OON) provider on June 8, 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 domiciliary or rest home visit (99336) rendered by the out-of-network (OON)
provider on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on May 24, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are
not supported.
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 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, the records do not show that
22 or more drug classes were tests on the date of service in question. 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 drug testing services (G0483) provided on May 24, 2021