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

 We decided that the Plan does not have to pre-approve lumbar laminectomy/discectomy (63048).  You asked the Plan to pre-approve lumbar laminectomy/discectomy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.  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 lumbar laminectomy/discectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical records do support lumbar decompression surgery at L5-S1. There is no documentation to support surgery at any other lumbar level. Only L5-S1 surgery should be approved.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar laminectomy/discectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar laminectomy/discectomy (63048).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the guidelines for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pre-approve BRAF genetic testing. We decided that the Plan does not have to pre-approve genetic testing for the remaining genes included in the Caris Molecular Intelligence tumor profile.
You asked the Plan to pre-approve Caris Molecular Intelligence tumor profiling. You say that the requested Caris Molecular Intelligence tumor profiling is medically necessary. The Plan says that the requested Caris Molecular Intelligence tumor profiling is not medically necessary.
We decided that the Plan has to pre-approve BRAF genetic testing.
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 Molecular Intelligence tumor profile. Our reviewer says that genetic testing for the BRAF gene is medically reasonable and necessary. Our physician reviewer found the enrollee is with axillary mass consistent with melanoma. Per NEJm 2017 377:1813-1823, for a patient with stage III melanoma, BRAF inhibition can be done. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of BRAF genetic testing have been met. Therefore, we decided that the Plan has to pre-approve BRAF genetic testing.
We also decided that the Plan does not have to pre-approve genetic testing for the remaining genes included in the Caris Molecular Intelligence tumor profile.
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 genetic testing for the remaining genes included in the Caris Molecular Intelligence tumor profile. Our reviewer says that genetic testing for the remaining genes included in this profile are not medically necessary for the enrollee's 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 genetic testing for the remaining genes in the Caris Molecular Intelligence tumor profile have not been met. Therefore, we decided that the Plan does not have to pre-approve genetic testing for the remaining genes included in the Caris Molecular Intelligence tumor profile.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF care. You say that the pain generated from the swelling and tenderness has inhibited the enrollee's abilities to perform well for therapy evaluations. You say that, with therapy, the enrollee should be able to be in a less restrictive environment. The Plan denied your request. The Plan says there are no noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF services.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care.
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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says surgery is approved but bone marrow aspiration 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has numbness in the hands, arms, and legs. The exam reveals borderline myelopathy. There is no specific indication provided to support the request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the planned cervical spine surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition, as also discussed above. The bone marrow aspiration is therefore not considered the standard of care for the enrollee's condition and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee notes loss of balance,
worsening gait, extremity numbness and tingling, and fasciculations for the past year. There is no specific
indication provided to support the request for bone marrow aspirate for the approved surgery. There is no
compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone
marrow aspiration in conjunction with the planned cervical spine surgery. There is a lack of large volume,
long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical
condition as discussed above. The bone marrow aspiration is not the standard of care for the enrollee's
condition and is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve bone marrow aspiration.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below his baseline and has not yet been shown to have reached a new plateau in function. Daily skilled services are reasonably required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition.
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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by you.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says the request for an
out-of-network specialist was reviewed by the Plan and is available within the enrollee's health Plan network. It was determined there is no reason to obtain services requested from an out-of-network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided by you.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services for the enrollee.
You asked the Plan to pre-approve the services. You say that ongoing PT involvement is medically necessary. The Plan denied your request. The Plan says the enrollee has had little progress.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had extensive therapy for this condition and the documentation does not indicate that the enrollee's functional level requires the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee can transition to an independent home exercise program. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion services (99601) provided on July 1, 2021 and July 5, 2021.  You asked the Plan to pay for code 99601. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, CPT code 99601 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion services (99601) provided on July 1, 2021 and July 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an in-network exception for endovascular ablation therapy to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve an in-network exception for endovascular ablation therapy to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.     The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an in-network exception for endovascular ablation therapy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for an infectious agent panel with 3-5 targets (87631) provided on August 2, 2021.  You asked the Plan to pay for an infectious agent panel. You say that this should be covered. The Plan denied your request. The Plan says the requirements for coverage have not been met.  The Plan must follow Medicare rules. Medicare rules say that panels of 3-5 pathogens are covered under limited circumstances. Specifically, the test must be ordered either in a healthcare setting that is equipped to care for and routinely does care for critically ill patients, or it must be ordered by an infectious disease specialist, unless an infectious disease specialist is not available.   We looked at the file and Medicare rules. The records do not show that this testing was ordered either in a healthcare setting that is equipped to care for and routinely does care for critically ill patients or by an infectious disease specialist. Based on this information, we decided that Medicare rules for coverage of an infectious agent panel have not been met. Therefore, we decided that the Plan does not have to pay for an infectious agent panel with 3-5 targets (87631) provided on August 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an external ambulatory insulin delivery system (A9274).  You asked the Plan to pre-approve an external ambulatory insulin delivery system. You say that the item is necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that disposable drug delivery systems, including elastomeric infusion pumps (A4305, A4306, A9274) are non-covered devices because they do not meet the Medicare definition of durable medical equipment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an external ambulatory insulin delivery system have not been met. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory insulin delivery system (A9274).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the parenteral nutrition solution provided from April 14, 2021, through April 20, 2021.  You asked the Plan to pay for the parenteral nutrition solution. You say that the item was supplied per the referring provider's prescription and the medical documentation should be reviewed. The Plan denied your request. The Plan says the records do not support 32 units 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 code B4185 is parenteral nutrition solution, not otherwise specified, 10 grams lipids.    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 parenteral nutrition solution. Our reviewer says that the submitted documentation was reviewed and does not meet the criteria for coverage. Our reviewer says that the units for the billed services cannot be verified.  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 parenteral nutrition solution have not been met. Therefore, we decided that the Plan does not have to pay for the parenteral nutrition solution provided from April 14, 2021, through April 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on April 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 procedure codes 81295 and 81298 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 81295 (MSH2 testing), 81298 (MSH6 testing), and 81432 (hereditary breast cancer related genomic testing). Codes 81295 and 81298 are column II codes with a modifier indicator of 1 when billed with column I code 81432.       The column II codes were not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 25, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered screening test.  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 testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 25, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99222) provided on January 25, 2021.  You asked the Plan to pay for code 99222. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on January 11, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99222) provided on January 25, 2021.