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

We decided that the Plan does not have to pre-approve Lidocaine/prilocaine cream.

You asked the Plan to pre-approve Lidocaine/prilocaine cream. You say that the medication is necessary. The Plan denied your request. The Plan says you have a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.

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 Lidocaine/prilocaine cream.

Benefits for Lidocaine/prilocaine cream 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on May 27, 2021 to August 13, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON outpatient mental health services. You say that you need mental health services and financial assistance. The Plan denied your request. The Plan says unauthorized, non-plan care is not covered.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for outpatient mental health services provided on May 27, 2021 to August 13, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an L4-S1 bilateral medial branch block.
You asked the Plan to pre-approve an L4-S1 bilateral medial branch block. You say that the requested L4-S1 bilateral medial branch block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested L4-S1 bilateral medial branch block.
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 an L4-S1 bilateral medial branch block. Our reviewer says that the enrollee does not meet criteria for the requested L4-S1 bilateral medial branch block. Our physician reviewer found the enrollee has chronic low back pain. She also has radicular symptoms. Her MRI shows multi-level facet joint disease but no disc herniation of spinal stenosis. She had a set of diagnostic medial branch blocks (MBBs) and the physician reported that she had 50% pain relief. The enrollee did not achieve 80% or greater pain relief from the diagnostic block. Therefore, the criteria of the LCD are not met, and the request is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an L4-S1 bilateral medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve an L4-S1 bilateral medial branch block
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 14, 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 code 99292 is not supported.

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 99292 is critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for primary service). 

We find that CPT code 99292 is not supported in the medical record. Specifically, there is no documentation of an additional 30 minutes of critical care time. 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 pay for the critical care services rendered on February 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic combinatorial pharmacogenomic test provided to the enrollee on June 2, 2021.

You asked the Plan to pay for the services. You say that this service is covered by Medicare. The Plan denied your request. The Plan says the order is not signed and the claim does not have the Z code as required.

The Plan must follow Medicare rules. Medicare rules say that the evidence does not support the use of GeneSight. 

Medicare does not consider this test to be medically reasonable or necessary. 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 GeneSight Psychotropic combinatorial pharmacogenomic test provided to the enrollee on June 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says 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 above. 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 enrollee does not require an intensive therapy program given the current level of function. Our reviewer says that the enrollee's rehabilitation needs can be met at a lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve an acute IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0427) provided December 19, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the copayment should be waived. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $265 copayment for Ambulance Services. The enrollee has been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the Ambulance Services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance transport (A0425, A0427) provided December 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on
April 14, 2020.
You asked the Plan to pay for the subsequent nursing facility care services. You say that the services rendered
were not related to the enrollee's hospice care. The Plan denied your request. The Plan says Original Medicare
would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's
terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the subsequent nursing facility care services provided on
April 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from December 12, 2019, to December 30, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the benefit limit was reached.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that there is a $2,500 benefit per year for out-of-network services when traveling outside the state of Idaho. The records show that out-of-network services were provided to the enrollee from December 12, 2019, to December 30, 2019. The enrollee's Traveler Benefit was exhausted prior to the claim for these services being processed. As the benefit limit was reached and paid by the Plan, the Plan is not responsible to pay for the services in question. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from December 12, 2019, to December 30, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health nursing visits.
You asked the Plan to pre-approve home health services. You say that the enrollee has a continued unstable cardiac status. The Plan denied your request. The Plan says the enrollee's medical issues are stable.
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 services. Our physician reviewer found that the enrollee has a history of hemiplegia following a cerebral infarction, insomnia, left hand contracture, and a history of falls. She is homebound due to taxing effort to leave home due to hemiplegia, poor endurance, dizziness, and impaired mobility. The records do not show that skilled nursing services are required to effectively provide treatment in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain her condition or prevent deterioration. Her medical conditions are stable and chronic. She has no new enteral feedings, complex wound care or other skilled nursing need. She has had skilled nursing visits with direction on safety and disease management. Therefore, additional visits 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health nursing visits.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different 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 above. 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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 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 presumptive and definitive drug testing provided on July 2, 2019.
You asked the Plan to pay for the testing services. You say that the codes are supported by the physicians custom profile. The Plan denied your request. The Plan says the documentation did not contain evidence of a relationship with the ordering physician.
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 codes 80307 and G0482 are not supported in the medical records. The documentation does not show that the enrollee is being treated by the ordering physician for a specific medical problem, or that the results are being used in the management of the enrollee's specific medical problem. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive and definitive drug testing provided on July 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee has osteoarthritis and has had conservative treatment.
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be considered medically reasonable and necessary when all of the above conditions are met. 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 Synvisc-One. Our reviewer says that the criteria for coverage of the requested injections has not been met. Our physician reviewer found while the patient is noted to have right knee pain, how this pain affects the enrollee's activities of daily living is not noted. There is no radiographic evidence of joint space narrowing, subchondral sclerosis, osteophytes or sub-chondral cysts. An MRI does show a concomitant meniscal tear, which does not appear to have been addressed. How long the enrollee has been taking medications is not noted. There is no evidence that the enrollee has completed a home exercise program or formal rehabilitative 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 Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on May 6, 2021.

You asked the Plan to pay for the dental services. You say that there was an emergent need for this medically necessary procedure. You say that it was imperative to your health that you be treated immediately, and the claim should be reconsidered. The Plan denied your request. The Plan says out-of-network dental services are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on May 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the
enrollee on February 22, 2020.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a shoulder-hand-wrist
orthosis (L3960) provided to the enrollee on February 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0648) provided to the enrollee on
November 30, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis
(L0648) provided to the enrollee on November 30, 2019.
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 May 24, 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 are not payable as 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 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 May 24, 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 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 based on the medical records provided you do not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 

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.