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

We decided that the Plan does not have to pay for the laboratory services coded 81210, 81235, 81275, 81276, 81301, 81311, 81292, 81321, 81206, 81272, 81295, 81298, 81317, and 81194 provided on May 17, 2021.

You asked the Plan to pay for the laboratory services. 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. 

We find that CPT codes 81210, 81235, 81275, 81276, 81301, 81311, 81292, 81321, 81206, 81272, 81295, 81298, 81317, and 81194 are not supported in the medical record. Specifically, the documentation shows that codes 81210, 81235, 81275, 81276, 81301, 81311, 81292, and 81321 were used to describe molecular genetic pathology testing. These services should be billed using 1 unit of code 81479 (for the entire bundled multi-test panel). In addition, the approved DEX-Z code should be entered adjacent in the comment/narrative field for the test.

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. This means codes 81206, 81272, 81295, 81298, 81317, and 81194 are not payable as billed.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81210, 81235, 81275, 81276, 81301, 81311, 81292, 81321, 81206, 81272, 81295, 81298, 81317, and 81194 provided on May 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve LTACH services.  You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on LTACHF criteria. The Plan states the enrollee could receive care in another setting and the Plan could review alternate settings if requested such as a skilled nursing facility, outpatient setting or home health care.  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 the enrollee was admitted with acute respiratory failure due to Coronavirus (COVID-19) pneumonia. The record indicates that the enrollee remains medically unstable with ongoing hypoxia and fever and requires acute 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 they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.   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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acute inpatient hospital care for the right total shoulder arthroplasty (CPT code 23472-RT), for the enrollee.  You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List and the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found a planned elective total shoulder arthroplasty was requested to be performed during an inpatient admission to the hospital. They have a past medical history significant for diabetes, heart disease, and thyroid disease, however, there was no recent note suggesting any of their conditions were unstable. The records did not support that the enrollee would require hospital services that would likely cross two (2) midnights for this typically ambulatory procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for the right total shoulder arthroplasty (CPT code 23472-RT), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the scaling and root planing services.  You asked the Plan to pre-approve the scaling and root planing services. You say that you would like reconsideration because the requested dental services are medically necessary. The Plan denied your request. The Plan says the information submitted by dentist shows that you do not have bone loss, discharge, redness and swelling of the gums and pockets depths of 5 mm or greater.  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. The Plan covers the scaling and root planing services when the services are medically necessary and reasonable.   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 scaling and root planing services. Our reviewer says that the provided radiographs do not reveal any significant bone loss around any of the teeth in any of the quadrants. Our physician reviewer found scaling and root planing is only possible where there is sufficient loss of bone around the teeth such that the root can be accessed for debridement.    In this instance, there is insufficient bone loss to allow for the root to be infected by microorganisms, and subsequently no reason or ability to debride the root surfaces.  Pocket depths greater than 3 mm can be caused by gingival inflammation, and this may be addressed by gingival cleaning on a lesser code level.  As the root surfaces are not accessible, there is no necessity or ability for scaling and root planing.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the scaling and root planing services have not been met. Therefore, we decided that the Plan does not have to pre-approve the scaling and root planing services.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the office visits (CPT code(s): 99204 and 99214), and hip x-ray (CPT code 73502) to be provided by an out-of-network provider.  

You asked the Plan to pre-approve the out-of-network services. You say that you have been seen by a neurosurgeon specialist and you stated that the doctor said you should see this provider because he is an orthopedic surgeon, and he could help you with your issue right now. The Plan denied your request. The Plan says the provider is an out-of-network provider and the service requested may be provided by a participating provider with this health plan.  

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visits (CPT code(s): 99204 and 99214), and hip x-ray (CPT code 73502) to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example, a skilled nursing facility or home with home health services.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and urinary tract infection. 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 the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  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 pre-approve CoreText injections (Q4246).

You asked the Plan to pre-approve the injections. You say that the injections are medically necessary. The Plan
denied your request. The Plan says this treatment is experimental and non-covered.

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 injections. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Medicare-approved major drug compendia and the current medical literature
designate CoreText (Wharton's jelly) injections as experimental and unproven for treatment for knee
osteoarthritis.

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 injections have not been met. Therefore, we decided that the Plan does not
have to pre-approve CoreText injections (Q4246).
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 enrollee requires LTACH care. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting.

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 that there is no documentation provided indicating medical necessity for admission to an 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 acute care hospital 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).

You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe and effective. 

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.  You asked the Plan to pre-approve the SNF services. You say that you would like reconsideration because you are bedridden and therapy in a SNF would get you walking and help you complete activities of daily living. The Plan denied your request. The Plan says you are now at a level where you can transition from daily skilled services to services that are provided intermittently.  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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Skilled Nursing Facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient services billed with DRG 872 provided from October 12, 2020, to October 19, 2020.  You asked the Plan to pay for the inpatient 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 payable.  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 principal diagnosis code of A41.9, defined as sepsis unspecified organism. 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 inpatient services. Our reviewer says that the documentation does not support the DRG billed. Our physician reviewer found while the enrollee presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. Emergency department notes stated that the enrollee was not toxic-appearing. Blood culture was negative for growth. Lactic acid was normal. Creatinine was 0.9mg/dL and Bilirubin was 0.56mg/dL. The enrollee remained alert and oriented throughout admission. There was no documentation of sepsis. Therefore, the billing of principal diagnosis code assignment of A41.9, sepsis unspecified organism was not supported by the documentation.   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 for the inpatient services billed with DRG 872 provided from October 12, 2020, to October 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home ventilator.  You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the criteria for coverage are not met. Our physician reviewer found the enrollee was recently hospitalized with acute-on-chronic hypercarbic respiratory failure. According to the pulmonologist's note, the primary cause of the respiratory failure was obesity-hypoventilation syndrome (OHS). A diagnosis of chronic obstructive pulmonary disease (COPD) is listed, but there are no pulmonary function tests to support this. The enrollee has known obstructive sleep apnea that is currently untreated. The criteria for coverage are not met and the ventilator is not reasonable or medically necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.