Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel (CPT code 37184) and angiography, extremity, unilateral, radiological supervision and interpretation (CPT code 75710) provided to the enrollee on March 18, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer found the operative report does not include documentation to support this procedure is an independent service.
In this case, a second unrelated percutaneous transluminal mechanical thrombectomy (CPT code 37184) was
not documented in the operative report as independent from other services provided during this session.
We looked at this coder's review, the file, and Medicare rules. Our records indicate a National Correct Coding
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 75710 and 37227. This PTP edit has a
modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate
NCCI modifier was not billed with this PTP code edit. 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 primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or
arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic
injection(s); initial vessel (CPT code 37184) and angiography, extremity, unilateral, radiological supervision
and interpretation (CPT code 75710) provided to the enrollee on March 18, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health care.
You asked the Plan to pre-approve home health care. You say that you are appealing this denial. The Plan
denied your request. The Plan says the denial of authorization for home health care is correct.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 home health care. Our reviewer says
that you do not meet the Medicare criteria for the requested home health care. Our physician reviewer found
the documentation does not support that you need additional skilled nursing or home health aide services to
provide treatment that is medically necessary. You have been medically stable without any recent
exacerbations or hospitalizations. Home health services are 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 home health care have not been met. Therefore, we decided that the Plan does
not have to pre-approve home health care.
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 more intensive care than what is available at a skilled nursing facility. The Plan denied your request. The Plan says the enrollee is near pre-admission baseline.
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 physician reviewer found that you were admitted to the acute care hospital for a lumbar fusion. Your medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for actinotherapy (ultraviolet light) (96900) provided May 27,
2021.
You asked the Plan to pay for actinotherapy. You say that kindly see the attached medical records and
reprocess the claim as your provider provided the services for this date of service. The Plan denied your
request. The Plan says this is considered to be experimental or investigational as the clinical value and
effectiveness of actinotherapy in the setting of pain have not been demonstrated in the peer review literature.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. The rules also say that experimental and investigational devices are not covered.
We looked the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage
of actinotherapy have not been met. Therefore, we decided that the Plan does not have to pay for actinotherapy
(ultraviolet light) (96900) provided May 27, 2021.
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 these services are medically necessary. The Plan
denied your request. The Plan says that you can safely be treated at the skilled nursing facility level of care.
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. 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 were admitted for peripheral vascular disease and had stent in lower extremity. Your 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 have a need for physical and/or occupational therapy, there is no documentation of a need
for an intensive rehabilitation program. 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. Our physician
reviewer found that your condition does not meet Medicare criteria for IRF 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 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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not
require 3 hours of therapy a day.
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 physician reviewer found
that the enrollee was admitted to the acute care hospital for coronavirus pneumonia and a urinary tract
infection. His medical problems are stable. The complexity of his nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While
he has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309)
rendered by the out-of-network (OON) provider on December 15, 2020.
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 subsequent nursing facility care, per day (99309) rendered by the out-of-network
(OON) provider on December 15, 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 the records provided support the need for IRF care. You say that you have 12 plus steps to navigate in the home and continue to have difficulty ambulating. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed in other settings.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for left leg weakness and lumbar spinal stenosis. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet joint nerves.
You asked the Plan to pre-approve destruction of lower or sacral spinal facet joint nerves. You say that the
services are necessary.
The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not
been met.
The Plan follows Medicare rules. Medicare rules say that the thermal radiofrequency destruction of cervical,
thoracic, or lumbar paravertebral facet joint (median branch) nerves are considered medically reasonable and
necessary for patients that meet specific criteria.
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 destruction of lower or sacral spinal
facet joint nerves. Our reviewer says that the services are not medically necessary. Our physician reviewer
found this is considered an experimental/investigational procedure because of the wide variation in efficacy
reported in the literature. Therefore, the request is considered 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 destruction of lower or sacral spinal facet joint nerves have not been met.
Therefore, we decided that the Plan does not have to pre-approve destruction of lower or sacral spinal facet
joint nerves
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
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 the enrollee is receiving appropriate care in the hospital and
there is no need to transfer to the LTACH at this time.
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. The enrollee
was admitted with acute respiratory failure due to acute on chronic renal failure and myocardial infarction. The
record indicates that the enrollee is not medically stable and requires ongoing critical care services. The
enrollee continues to receive acute 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. Our physician reviewer found that the enrollee's 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 for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve chiropractic services. You say that chiropractic services are medically necessary for your condition. The Plan denied your request. The Plan says criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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 chiropractic services Our reviewer says that the requested chiropractic services are not medically reasonable and necessary according to the Medicare rules. Our physician reviewer found the enrollee is a 66-year-old man with a diagnosis of Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder. The enrollee has low back pain with pain in the right buttock and down the right leg. In this case, the case file does not contain documentation of a subluxation, shown by x-ray or by physical exam, which has resulted in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of chiropractic services have not been met. Therefore, we decided that the Plan does not have to pre-approve chiropractic services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a removal of stent from urethra or bladder (52310) provided on June 30, 2021.
You asked the Plan to waive the copayment for a removal of stent. You say that you should not have to pay your copayment due to the quality of care provided. 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 $300 copayment for all services other than certain wound care services provided at an ambulatory surgical center. You have been asked to pay a $300 copayment for a removal of stent. A removal of stent falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. 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. Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of care received. Therefore, we decided that the Plan does not have to waive the copayment for a removal of stent from urethra or bladder (52310) provided on June 30, 2021.
Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review
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 IRF care is medically reasonable and necessary. 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 the patient was admitted for pneumonia. Medical problems are stable. There
are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies,
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
While the patient has 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 this patient 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 the GeneSight PGx test provided on June 9, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this test is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that PGx testing is covered for the indications established
in the applicable LCD.
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 testing. Our reviewer says that the
requested GeneSight PGx test is not medically reasonable and necessary. Our physician reviewer found that the
medical records do not document a specific psychiatric history, that a specific plan for medication change is
being considered, which medications may need gene testing, or that the panel was being ordered and used by
the provider for medical management of the member's condition. The requested GeneSight testing is not
medically reasonable and necessary according to the coverage criteria established in the LCD.
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 testing have not been met. Therefore, we decided that the Plan does not have
to pay for the GeneSight PGx test provided on June 9, 2021.