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 to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 complexity of your nursing, medical and rehabilitation needs do not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational 
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 
 
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 the drug testing rendered on December 17, 2020.
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 were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of
service (POS) code.
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing
rendered on December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 29, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 29, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.

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 inpatient psychiatric care from September 29, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment from September 29, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place. It did not appear that the services were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from September 29, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 29, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on April 12, 2020.
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 paid.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 (moderate sedation services) has a PC/TC indicator of 3 and no separate PC payment. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on April 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray provided on May 18, 2021 by a non-participating provider.
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 were rendered by a non-participating 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 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 office visit and x-ray provided on May 18, 2021 by a non-participating provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve stellate ganglion block injection (64510).
You asked the Plan to pre-approve stellate ganglion block injection. You say that this request is medically necessary. The Plan denied your request. The Plan says the requested procedure is not medically necessary and not standard of care
The Plan follows Medicare rules. Medicare rules say that the requested procedure is 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 stellate ganglion block injection. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 69-year-old male with a history of chronic back pain/chronic pain syndrome. In addition, the enrollee has had pain in the right side of his face x1 month, related to shingles/trigeminal neuralgia. A stellate ganglion block (also called a cervicothoracic sympathetic block) is used primarily to treat Complex Regional Pain Syndrome (CRPS), but has also been used to treat refractory angina, phantom limb pain and vascular insufficiency (such as Raynaud's or frostbite), hyperhydrosis and other conditions. The stellate ganglion block is an injection of medication into the nerves that can help relieve pain in the head, neck, upper arm and upper chest. The clinical effectiveness of stellate ganglion block for the requested service can be defined as undetermined. The review has determined that the requested stellate ganglion block is not medically reasonable or 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 stellate ganglion block injection have not been met. Therefore, we decided that the Plan does not have to pre-approve stellate ganglion block injection (64510).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for interpretation and report only of rhythm electrocardiogram
coded as 93042 provided February 26, 2021.
You asked the Plan to pay for interpretation and report only of rhythm electrocardiogram. You say that you
would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim
was not billed with an appropriate modifier.
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 93042
has a bundled relationship with code 12002 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for interpretation and report only of rhythm electrocardiogram coded as
93042 provided February 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on February 9, 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 claim was billed incorrectly. 
 
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of 
service (POS) code. 
 
We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a 
laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have 
been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the definitive drug 
testing rendered on February 9, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an abdominal ultrasound (76705) provided on May 19, 2021.
You asked the Plan to waive the copayment for an abdominal ultrasound. You say that you believe that the procedure at issue was a regular diagnostic test with a copayment of $25. The Plan denied your request. The Plan says the correct copayment was applied.
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 $105 copayment for Medicare-covered radiological diagnostic services, not including X-rays. You have been asked to pay $96.11 for an abdominal ultrasound. An abdominal ultrasound falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay less than or equal to 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 copayment for an abdominal ultrasound (76705) provided on May 19, 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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for polycarbonate or equal lenses and vision accessory provided on May 19, 2021.

You asked the Plan to pay for polycarbonate or equal lenses and vision accessory. The Plan denied your request. The Plan says that the plan paid for standard frames and progressive lenses. After the Plan paid benefits for eyeglasses (lenses and frames) you are responsible for the cost of any additional purchases. This means that the cost for polycarbonate or equal lenses and vision accessory are the financial responsibility of the member.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan paid for the standard frames and progressive lenses and you are responsible for the cost of any additional purchases. Therefore, we decided that the Plan does not have to pay for polycarbonate or equal lenses and vision accessory provided on May 19, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 3 fractions (treatment sessions) of Stereotactic Body Radiation Therapy (SBRT).
You asked the Plan to pre-approve SBRT. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are 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 SBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, one site of metastasis in the lumbar spine, in the setting of widespread disease, is progressive and symptomatic. However, based on July 5, 2021 computerized tomograph (CT) imaging, she also has progression in other bony sites and the liver. The appeal letter justifies SBRT by stating that there are "no additional levels of disease and much of her parenchymal disease has in fact responded to systemic therapy." however the CT imaging reports a growing liver metastasis and multiple bony sites progressing. Lesions are noted at L2 and S2 (though not mentioned that these are progressing).
Therefore, this is not a situation of either oligometastases or oligoprogression. For such a situation, SBRT would not be considered to be furnished in accordance with accepted standards of medical practice. Therefore, the enrollee does not meet criteria for the requested 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 SBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve 3 fractions (treatment sessions) of Stereotactic Body Radiation Therapy (SBRT).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound services coded as 76770 provided May 4,
2021.
You asked the Plan to pay for the ultrasound services. You say that you would like this claim reprocessed for
medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate
modifier.
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 76770
has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid as a separate
line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided
that the Plan does not have to pay for the ultrasound services coded as 76770 provided May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for GeneSight testing provided on March 17, 2021.
You asked the Plan to pay for genetic testing. You say that this testing is covered by Medicare. The Plan denied
your request. The Plan says the denial of payment for this testing is correct, because this testing is not covered
by Medicare and the order for this testing was not signed by the enrollee's treating physician.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does
not have to pay for GeneSight testing provided on March 17, 2021
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trastuzumab.
You asked the Plan to pre-approve Trastuzumab. The Plan denied your request. The Plan says the enrollee has
not tried and failed at least three of Ogivri, Herceptin Hylecta, Kanjinti, Herzum, and Trazimera.
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 Trastuzumab. Our physician reviewer
found that the enrollee has gastric cancer. The Plan requires a trial of Ogivri, Herceptin Hylecta, Kanjinti,
Herzum, and Trazimera before they will approve the requested drug. In this case, the enrollee has not tried and
failed the required drugs. There is no documentation provided indicating that the Plan's required drugs would
likely be less effective 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 Trastuzumab have not been met. Therefore, we decided that the Plan does not
have to pre-approve Trastuzumab
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 the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee continues to receive acute critical care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the inpatient behavioral health services provided from April 23, 2020 to April 29, 2020.

You asked the Plan to pay for the inpatient behavioral health services. You say that the inpatient behavioral health services provided from April 23, 2020 to April 29, 2020 were medically necessary. The Plan denied your request. The Plan says that the services are not covered.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. The rules also 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 pay for the inpatient behavioral health services. Our reviewer says that the inpatient behavioral health services provided from April 23, 2020 to April 29, 2020 were medically necessary. Our physician reviewer found this enrollee did appear to require inpatient mental health treatment as he was a danger to himself but not others and was cooperative and compliant. It did appear that active treatment was taking place. It did appear that the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. It did appear that the records were supervised and evaluated by a physician. Based upon review of the records provided, the enrollee does meet the criteria for acute inpatient mental health treatment as this enrollee was shown to be a danger to himself but not others. He was not showing any agitation or aggression and without perceptual disturbance including auditory or visual hallucinations. 

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 inpatient behavioral health services have been met. Therefore, we decided that the Plan has to pay for the inpatient behavioral health services provided from April 23, 2020 to April 29, 2020.

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.