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

 We decided that the Plan has to pre-approve radiation therapy.  You asked the Plan to pre-approve radiation therapy. You say that the records provided support the need for the radiation therapy being requested. The Plan denied your request. The Plan says that the guidelines do not support the routine use of the requested type of treatment for the enrollee's cancer type.  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 radiation therapy. Our reviewer says that radiation therapy is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has limited metastatic disease and the criteria for coverage have been met. Our physician reviewer found that Stereotactic body radiation therapy (SBRT) is within the accepted standards of care for this enrollee and in this circumstance.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve radiation therapy.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on August 18, 2020.  You asked the Plan to pay for GeneSight Psychotropic testing. You say that this is a covered service. The Plan denied your request. The Plan says this test is not supported.  The Plan must follow Medicare rules. Medicare rules say that in order for any Pharmacogenomics services to be covered, the patient's medical record must clearly reflect that the criteria for coverage have been met. The rules also say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. Although the order form indicates that the criteria for coverage are met, no medical records from the ordering physician have been submitted to verify this information. Based on this information, we decided that Medicare rules for coverage of GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for GeneSight Psychotropic testing (81479) provided on August 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a fentanyl patch.  You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 a fentanyl patch.   Benefits for self-administered 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical trays (CPT code A4550) provided to the enrollee on May 14, 2021.  You asked the Plan to pay for the surgical trays. You say that the claim should be paid. The Plan denied your request. The Plan says payment for covered services are always bundled into payment for other services not specified. The Plan states as the claim was billed with a CPT code which is always bundled; the Plan finds that Medicare rule for payment of this claim has not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for surgical trays (CPT code A4550) provided to the enrollee on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 and the molecular pathology procedure coded G0452 provided on March 11, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel and the molecular pathology procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 81455 and G0452 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (eg, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NPM1, NRAS, MET, NOTCH1, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed for the billed date of service. The documentation submitted did not include documentation of molecular pathology procedure; physician interpretation and report for the billed date of service.  Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel and the molecular pathology procedure have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 81455 and the molecular pathology procedure coded G0452 provided on March 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee is ambulating 15 feet and physical therapy is recommended. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing facility (SNF) setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve intravascular ultrasonography services.  You asked the Plan to pre-approve the requested services. You say that the use of the treatment is medically necessary for the treatment of the enrollee's May-Thurner's Syndrome. The Plan denied your request. The Plan says there are other options available that are universally acceptable.  The Plan follows Medicare rules. Medicare rules say that endovenous procedure are only covered under certain medical indications.   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 requested services. Our physician reviewer found that the enrollee is recently status post at least 11 endovenous procedures in June and July of 2021. It is documented that his symptoms are worse on the right than the left, and the symptoms on the left are 2 out of 10. He is scheduled for bilateral lower extremity sclerotherapy. On physical examination the enrollee has pedal edema bilaterally. He has a diagnosis of peripheral vascular disease as documented. There is no evidence of whole leg edema on either side and no evidence of proximal venous disease on any noninvasive study. The documentation does not support the medical necessity of the invasive venous procedures requested.  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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve intravascular ultrasonography services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99284) provided on July 24, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.  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 99284 is a column II code to column I code 99285. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (99284) provided on July 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance services provided on March 29, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not separately payable.  The Plan must follow Medicare rules. Medicare rules say that ambulance transportation during an inpatient stay is included in the Part A costs.   We looked at the file and Medicare rules. The records show that the enrollee in this case was under inpatient status when the ambulance services were provided. Ambulance services provided during an inpatient stay are not separately payable. Payment is included in the Part A facility payment. 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 ambulance services provided on March 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 25, 2021.  You asked the Plan to pay for the GeneSight Psychotropic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.  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 81479 is not supported in the medical record. Specifically, the documentation does not support that this service was billed with the appropriate DEX-Z code identifier was not submitted on the claim. Based on this information, we decided that Medicare rules for coverage of the GeneSight Psychotropic testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic testing provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 28, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on July 28, 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 there is no documentation provided necessitating 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 present setting 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.  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 you need inpatient rehabilitation services to recover fully and return to your prior level of function. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy and nursing needs can be provided at a lower 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. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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. 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an additional 12 routine transportation trips (A0120).  You asked the Plan to pre-approve an additional 12 routine transportation trips. You say that you need transportation to medical appointments. The Plan denied your request. The Plan says you have utilized the maximum number of transportation trips allowed per year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 trips per year.    We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve an additional 12 routine transportation trips (A0120).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a two level radiofrequency ablation (RFA) procedure (C3-4, C5-6) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the requested service is not supported without confirmation of pain relief from medial branch blocks.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the only level receiving 2 medial branch blocks was the bilateral C4-C5 level. The review has determined that the enrollee does not meet the criteria for RFA.  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 a two level radiofrequency ablation (RFA) procedure (C3-4, C5-6) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from November 25, 2020, to November 28, 2020.  You asked the Plan to pay an additional amount for the inpatient care. You say that the billing of secondary diagnosis code J96.21 is supported. The Plan denied your request. The Plan says the provided documentation does not support the billing of the secondary diagnosis code J96.21, acute and chronic respiratory failure with hypoxia.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.  In this case, you billed the inpatient services provided with secondary diagnosis of, J96.21, defined as acute and chronic respiratory failure with hypoxia. 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 an additional amount for the inpatient care. Our reviewer says that the billing of secondary diagnosis code J96.21 is not supported. Our physician reviewer found the provided documentation indicates acute on chronic respiratory failure with hypoxia was noted. The reviewer found that oxygen was used at 2L as a baseline and required a non-rebreather due to worsening distress and hypoxia. The reviewer found that after treatment and at the time of admission, requirement was 3L which is near baseline and would not describe an acute on chronic respiratory failure with hypoxia as the enrollee was responding to the treatment already and was near her baseline on admission. Therefore, the reviewer found that the billing of the secondary diagnosis code J96.21 is not supported.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay an additional amount for the inpatient hospital care provided from November 25, 2020, to November 28, 2020.