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

We decided that the Plan does not have to pay for the genetic testing provided on March 19, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were 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 March 19, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 14, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. You say that your lab performed all the tests that were ordered by the referring physician. The Plan denied your request. The Plan says prior authorization was not obtained for this lab work. The Plan says that the referring provider is also out-of-network.
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 lab work provided on December 14, 2020 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) scan of skull base to mid-thigh (78815).
You asked the Plan to pre-approve a PET scan of skull base to mid-thigh. You say that this requested imaging service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says that the criteria for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 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 a PET scan of skull base to mid-thigh. Our reviewer says that this request is medically necessary. Our physician reviewer found while the patient has had the limit of PET/CT scans per NCD guidelines local guidelines also apply. While the 2 most recent PET/CT scans have been negative, there is a new area of tubular abnormality in the right upper quadrant which is of some concern despite the lack of fluorodeoxyglucose (FDG) uptake in the past. The other clinical factor which continues to warrant surveillance is the history of weight loss, fever and night sweats. Due to all these clinical factors a surveillance PET/CT is medically necessary and reasonable at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan of skull base to mid-thigh have been met. Therefore, we decided that the Plan has to pre-approve a positron emission tomography (PET) scan with concurrently acquired computed tomography (CT) scan of skull base to mid-thigh (78815).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on March 27, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were 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 March 27, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on April 6, 2021.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be billed with code 81479 to be considered for coverage. We looked at the file and Medicare rules. In this case, the Guardant360 testing was billed with multiple codes. For coverage consideration, this testing must be billed with singular code 81479. 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 Guardant360 testing provided on April 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861, E1007, E1012, E2311) for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the documentation does not clearly reveal a qualifying diagnosis for a group 3 power wheelchair. The documentation does not indicate the enrollee is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift, or utilizes intermittent catheterization for bladder management, or needs a power seating system to manage increased tone or spasticity. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair (K0861, E1007, E1012, E2311) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that you need these procedures done in order for your dentures to fit. The Plan denied your request. The Plan says these services are not covered under your benefit package.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebroplasty (PVA) for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there was no clinical documentation submitted documenting the degree of loss of vertebral height.
The Plan must follow Medicare rules. Medicare rules say that PVA is covered if the LCD criteria 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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. There is no documentation of the degree of L5 vertebral body height loss. Also, there is no clear documentation that the fracture is less than 6 weeks old. The imaging suggests it may be subacute. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebroplasty (PVA) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve routine transport. You say that you have no other means of transportation and need transportation for appointments. The Plan denied your request. The Plan says the denial of authorization for additional routine transportation is correct, because routine transportation beyond 60 one-way trips per calendar year is not covered by the Plan.
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 60 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 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services coded 01402 and the femoral nerve injection coded 64447 provided on April 19, 2021.
You asked the Plan to pay for the anesthesia services and the femoral nerve injection. 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 codes 01402 and 64447 is not supported in the medical record. Specifically, the submitted medical records include anesthesia record indicating anesthesia was performed; however, it does not support 162 units billed. Therefore, 162 units of code 01402 is not supported by the documentation. In this case, we have confirmed that code 64447 has a bundled relationship with code 01402 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Based on this information, we decided that Medicare rules for coverage of the anesthesia services and the femoral nerve injection have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 01402 and the femoral nerve injection coded 64447 provided on April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is 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 ongoing skilled therapy and nursing needs can be provided in 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 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May 5, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you have financial assistance and you are unable to afford this. The Plan denied your request. The Plan says this copayment was charged correctly. The Plan says that your financial assistance program only applies to Plan facilities-- it does not apply to city ambulance services.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for the ambulance services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services you received on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 48 additional routine transportation trips.
You asked the Plan to provide additional routine transportation. You say that you need this transportation to get to your appointments. The Plan denied your request. The Plan says this request exceeds the maximum number of trips covered by your supplemental transportation benefit. The request for additional trips is not covered by your benefit.
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 24 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that your request exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide 48 additional routine transportation trips.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta, 20-10mg capsule.
You asked the Plan to pre-approve Nuedexta. You say that this is the drug approved by the Food and Drug Administration (FDA) to specifically treat PseudoBulbar Affect (PBA). The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare 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 Nuedexta, 20-10mg capsule.
Benefits for Nuedexta 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the AlloSure testing provided on March 4, 2021.

You asked the Plan to pay for the testing services. You say that the test is used to monitor the probability of acute rejection. The Plan denied your request. The Plan says the use of testing would be considered investigational/experimental.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We looked at the file, and Medicare rules. In this case, there were insufficient medical records that showed clinical suspicion of rejection. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the AlloSure testing provided on March 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the professional services for allergen immunotherapy coded 95117 and professional services for the supervision of preparation and provision of antigens for allergen immunotherapy coded 95165 provided from June 12, 2018 to June 29, 2018.
You asked the Plan to pay for the professional services for allergen immunotherapy and professional services for the supervision of preparation and provision of antigens for allergen immunotherapy. 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 95117 and 95165 are not supported in the medical record. Specifically, diagnostic services (including clinical diagnostic laboratory tests) provided to an enrollee by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within three days prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment, unless there is no Part A coverage.
Based on this information, we decided that Medicare rules for coverage of the professional services for allergen immunotherapy and professional services for the supervision of preparation and provision of antigens for allergen immunotherapy have not been met. Therefore, we decided that the Plan does not have to pay for the professional services for allergen immunotherapy coded 95117 and professional services for the supervision of preparation and provision of antigens for allergen immunotherapy coded 95165 provided from June 12, 2018 to June 29, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the personal care services provided from July 11, 2020, to July 23, 2020.
You asked the Plan to pay for the services provided. You say that going to a rehabilitation facility was not an option. The Plan denied your request. The Plan says custodial care is not covered.
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered. We looked at the file and Medicare rules. We find that the services at issue in this case are considered custodial in nature. There are no records to show that services from a skilled professional were provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the personal care services provided from July 11, 2020, to July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 you are a 74-year-old male with cerebrovascular accident, deep vein thrombosis, feeding tube, and chronic right hip stage 4 decubitus ulcer. While there are identifiable skilled nursing service needs, there are no identifiable skilled therapy service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).