Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds (CPT code K0863) and accessories (CPT code(s): E2363 X 2, E2377, E2313, E1028 X 2, E1007, E1012, E0955, E2623)  You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says you do not have a qualifying diagnosis causing mobility limitation for which a group 3 Very Heavy-Duty power wheelchair (CPT code K0863) is medically needed.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 DME. Our physician reviewer found based on the medical records provided there is documentation that you have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. Your mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair due to your level of shortness of breath and fatigue. There is documentation that you can safely operate a power mobility device. You have a qualifying diagnosis for a group 3 power wheelchair. Your mobility impairment appears to be due to your cardiac and pulmonary disease and your obesity and not due to a neurologic condition, myopathy or congenital skeletal deformity. You appear to be eligible for a group 2 power wheelchair.  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 DME have not been met. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds (CPT code K0863) and accessories (CPT code(s): E2363 X 2, E2377, E2313, E1028 X 2, E1007, E1012, E0955, E2623)
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight test provided to the enrollee on May 6, 2021.  You asked the Plan to pay for the testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. Medicare rules say that the evidence does not support the use of the GeneSight test.  Medicare does not consider the denied testing to be medically reasonable or necessary. 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 test provided to the enrollee on May 6, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient services provided from August 30, 2020, to September 2,
2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the billed
diagnosis code is not supported.
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 J96.01. 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 services. Our reviewer says that the billed diagnosis code is supported by the
records provided. Our physician reviewer found that the enrollee is an 86-year-old male with chronic
obstructive pulmonary disease (COPD) who presented to the hospital with a COPD exacerbation. Rhonchi and
decreased air sounds were noted on examination. Pulse oximetry measured 88% on arrival to the emergency
department. Acute respiratory failure with hypoxia was listed as a diagnosis. This diagnosis is supported in the
documentation as the enrollee presented and was admitted with hypoxia dependent on oxygen supplementation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the
inpatient services provided from August 30, 2020, to September 2, 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a tuberculosis screening (86480) provided on June 17, 2021.

You asked the Plan to pay for a tuberculosis screening. You say that this is supported in the records. The Plan denied your request. The Plan says this was a screening service.

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 test at issue in this appeal, a tuberculosis screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for a tuberculosis screening (86480) provided on June 17, 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 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 member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 pay for hearing aid check (92593) conformity evaluation (V5020) provided July 7, 2021.  You asked the Plan to pay for the hearing services. You say that the visit on February 19, 2014 covered the hearing aid evaluation and fitting so you assumed this visit would be covered. The Plan denied your request. The Plan says this service is not covered under the Plan benefits.  Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for up to two follow-up visits in the first 12 months after purchase of hearing aids.   We looked at the file, and the Plan's rules. In this case the enrollee received their hearing aids in 2014. The price of the hearing aid(s) includes up to two follow-up visits in the first 12 months after purchase. The evaluation at issue is well beyond the allowable time frame and the benefit does not include or cover additional visits. Based on this information, we decided that the Plan's rules for coverage of the hearing services have not been met. Therefore, we decided that the Plan does not have to pay for hearing aid check (92593) conformity evaluation (V5020) provided July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Restasis for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Restasis for the enrollee.   Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the annual wellness visit (CPT code G0439) provided on May 10, 2021.  You asked the Plan to pay for the annual wellness visit. You say that you feel the February 23, 2021, visit did not meet the standards of a wellness checkup since you did not have a wellness checkup in 2019 or 2020, and your health issues were not addressed to your satisfaction at the February 23, 2021, visit. The Plan denied your request. The Plan says this benefit is covered once per year.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   Review of the file shows that you had two (2) annual wellness exams within twelve (12) months; therefore, you exceeded the benefit limit. The health plan contract says if you've had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. Therefore, we decided that the Plan does not have to pay for the annual wellness visit (CPT code G0439) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) for the enrollee.  You asked the Plan to pre-approve the assessment. You say that this is needed for treatment of malignant neoplasm of overlapping sites of left female breast. The Plan denied your request. The Plan says this request is considered investigational.  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 assessment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bioimpedance spectroscopy (BIS) is used to assess lymphedema by measuring limb fluid content as an electric current passes through cell membranes and tissues. Bioimpedance spectroscopy is used for diagnosis as well as assessing treatment response. Bioimpedance spectroscopy (BIS) is an increasingly utilized diagnostic technique that allows for the subclinical detection of lymphedema, prior to clinically evident disease. Early detection allows early treatment for prevention of clinically significant lymphedema. It has become a standard of care. However, it is indicated after surgery and it appears that this enrollee has not yet undergone treatment. The service 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 the assessment have not been met. Therefore, we decided that the Plan does not have to pre-approve bioimpedance spectroscopy (BIS) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on July 2, 2020.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.   We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple code. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on July 2, 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 inpatient rehabilitation services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's care needs can be met in an alternate setting.  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 the enrollee's 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 this 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 an Intracept procedure.  You asked the Plan to pre-approve the requested services. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says the effectiveness of the procedure has not been demonstrated in peer-reviewed literature.  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 requested services. Our physician reviewer found that the Intracept procedure is experimental. More research is needed to show safety and efficacy. Therefore, the requested service is not considered 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services coded 99291 provided on April 29, 2021.  You asked the Plan to pay for the critical care services. 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.  In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.    We find that CPT code 99291 is not supported in the medical record. Specifically, the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services coded 99291 provided on April 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the manual wheelchair and accessories.  You asked the Plan to pre-approve the manual wheelchair and accessories. You say that you would like reconsideration because your wheelchair broke and you require this for mobility. The Plan denied your request. The Plan says you do not have a mobility impairment that significantly impairs your ability to participate in mobility related activities of daily living.  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 manual wheelchair and accessories. Our reviewer says that the criteria for coverage per LCD L33788 for the manual wheelchair have not been met. Our physician reviewer found the documentation does not support that you have a mobility limitation that significantly impairs your ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. The documentation does not reveal a detailed gait and  upper extremity and lower extremity neuromuscular evaluation to support why you are unable to use a cane or walker. The documentation is not clear that the  use of the wheelchair will significantly improve your mobility-related activities of daily living.  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 manual wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the manual wheelchair and accessories.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for SNF services provided from May 29, 2021, through  May 31, 2021.  You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says SNF services were not medically necessary.  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 pay for SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, it is my opinion that the enrollee did not qualify for SNF coverage. The enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs were custodial and, as a practical matter, could be provided at a lower level of care (ex. home, assisted living, long term 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from May 29, 2021, through May 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 17, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 7, 2021.  You asked the Plan to pay for the targeted genomic sequence analysis panel. 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.  In this case, the CPT Code Manual definition of code 0242U is targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements.  We find that CPT code 0242U is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting, place of service 11. Based on this information, we decided that Medicare rules for coverage of the targeted genomic sequence analysis panel have not been met. Therefore, we decided that the Plan does not have to pay for the targeted genomic sequence analysis panel coded 0242U provided on April 7, 2021.