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

We decided that the Plan does not have to pay for the telephone evaluation and management service provided
on October 4, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the telephone evaluation and management service. You say that the service was
medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the telephone evaluation and management service provided on October 4, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary.
The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the present setting where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (procedure code 00918) provided to the enrollee on July 4, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a surgical code that appropriately crosswalks to the anesthesia services must be reported to support the anesthesia code.
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 00918 is "Anesthesia for transurethral procedures (including urethrocystoscopy); with fragmentation, manipulation and/or removal of ureteral calculus." We asked our coder 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 services at issue in this case were not supported by the medical records. Our reviewer found the medical records submitted by the anesthesia provider indicates that the surgery performed, along with anesthesia code 00918 on July 4, 2021 was 52332 - cystourethroscopy, with insertion of indwelling stent. CPT 00918 is not the appropriate anesthesia code to report with procedure 52332 according to ASA CROSSWALK, therefore 00918 is not eligible for reimbursement consideration.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (procedure code 00918) provided to the enrollee on July 4, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services for the enrollee.
You asked the Plan to pay for inpatient hospital services. You say that this is medically necessary. The Plan
denied your request. The Plan says that there is no documentation provided to support the expectation the
enrollee will require a greater than 2 midnight stay.
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 pay for inpatient hospital services. Our reviewer
says that inpatient hospital services are not medically reasonable and necessary. The enrollee is undergoing a
planned total shoulder arthroplasty. She is medically stable and has been provided medical clearance to
undergo this elective procedure. The planned procedure is not listed on the Inpatient Only List. The procedure
is currently approved as an ambulatory procedure. There is no documentation provided to support the
expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage for inpatient hospital 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 inpatient hospital services have not been met. Therefore, we decided that the
Plan does not have to pay for inpatient hospital services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve surgical extractions (D7210) of teeth #s 6 and 11.  You asked the Plan to pre-approve surgical extractions (D7210) of teeth #s 6 and 11. The Plan denied your request. The Plan says the x-rays show each tooth to have one root and no need for sectioning or removal of bone to accomplish the extractions. 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 surgical extractions (D7210) of teeth #s 6 and 11 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 surgical extractions (D7210) of teeth #s 6 and 11. Our reviewer says that the documentation provided does not meet the criteria for coverage for surgical extractions (D7210) of teeth #s 6 and 11. Our physician reviewer found tooth #'s 6 and 11 have intact crowns and single roots without evident curvatures. Our reviewer also found that it appears that removal via elevation and forceps is possible.  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 surgical extractions (D7210) of tooth #'s 6 and 11 have not been met. Therefore, we decided that the Plan does not have to pre-approve surgical extractions (D7210) of teeth #s 6 and 11.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home mechanical ventilator.  You asked the Plan to pre-approve a home mechanical ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says that the request for a home mechanical ventilator set in AVAPS mode that could be delivered by BiPAP is not covered.  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 a home mechanical ventilator. Our reviewer says that a home mechanical ventilator is not medically reasonable and necessary. You have oxygen dependent COPD and were admitted with recurrent coronavirus pneumonia. There is very limited data provided and includes only arterial blood gas analysis (ABG) during acute illness. The results reflect a contraction alkalosis which would blunt respiratory drive and raise carbon dioxide levels from baseline.  That noted, this evaluation will proceed with the assumption that the member has chronic respiratory failure secondary to COPD. A request is now made for a home mechanical ventilator with average volume-assured pressure support (AVAPS) mode to assure adequate tidal volume ventilation. There is no documentation to suggest a BiPAP with back up rate and AVAPS was utilized. The review has determined that this patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. Our physician reviewer found that your condition does not meet Medicare criteria for a home mechanical ventilator.  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 home mechanical ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services provided to the enrollee on July 8, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  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 97010 is "Application of a modality to 1 or more areas; hot or cold packs."  We find that CPT code 97010 is not supported in the medical record. Specifically, this code has a status indicator of "B" which indicates that it cannot be paid separately, and payment for this code is always bundled into payment for other codes not specified. 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 physical therapy services provided to the enrollee on July 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nplate.
You asked the Plan to pre-approve Nplate. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the accepted use criteria have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Nplate. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found based on the medical records provided and the Medicare-approved major drug compendia there is no documentation that the Nplate meets Medicare criteria for medically reasonable and necessary for the patient. Nplate is indicated for chronic immune thrombocytopenic purpura (ITP) in patients who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy. Provided records do not document the enrollee has chronic ITP (that is ITP for at least 6 months) or has failed treatment with corticosteroids. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nplate have not been met. Therefore, we decided that the Plan does not have to pre-approve Nplate.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on April 4, 2021.  You asked the Plan to pay for the EKG services. You say that you would like this claim reprocessed and approved for payment as the services were medically necessary. The Plan denied your request. The Plan says required documentation for payment was not provided.  The Plan must follow Medicare rules. The Plan follows Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.     We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. The Plan has provided evidence that they requested medical records and the provider responded that the patient was not treated during the dates in question. Therefore, we decided that the Plan does not have to pay for the electrocardiogram (EKG) provided on April 4, 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 the enrollee requires inpatient acute rehabilitation in effort to facilitate increased independence and return to her home and to her community with improved quality of live. The Plan denied your request. The Plan says the enrollee does not meet all the required Medicare criteria for admission to an Inpatient Rehabilitation Facility.    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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer found that the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our physician reviewer also found that there is not a reasonable expectation that this patient 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Benzotropine.
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 Benzotropine.
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 physical therapy services provided to the enrollee on June
21, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the provider did not bill as required by Medicare coding regulations.
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 97010 is "Application of a modality to 1 or more areas;
hot or cold packs."
We find that CPT code 97010 is not supported in the medical record. Specifically, this code has a status
indicator of "B" which indicates that it cannot be paid separately, and payment for this code is always bundled
into payment for other codes not specified. 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
physical therapy services provided to the enrollee on June 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for chiropractic physical therapy provided to the enrollee between October 15, 2020, and December 14, 2020.  You asked the Plan to pay for the services. You say that this is a substantial amount of money. The Plan denied your request. The Plan says this is not a covered benefit.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic physical therapy provided to the enrollee between October 15, 2020, and December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 8, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the provider did not bill as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72170 is a column II code to column I code 72190. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve more than 3 boxes of Depends a month.  You asked the Plan to pre-approve more than 3 boxes of Depends a month. You say that an amount greater than the Plan's limit is necessary for you in this case. The Plan denied your request. The Plan says the Plan does not provide coverage for more than 3 units.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. However, the Plan's contract says that they cover 3 units of a single item per month. In this case, you are requesting an amount over the Plan's limit. According to the Plan's contract, coverage cannot be made for more than 3 items. Therefore, we decided that the Plan does not have to pre-approve more than 3 boxes of Depends a month.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for genetic testing (81529) provided on October 11, 2021.  You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan denied your request. The Plan says this out-of-network service was not preauthorized.  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 service 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 genetic testing (81529) provided on October 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD) (E0483).  You asked the Plan to pre-approve a HFCWOD. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.  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 a HFCWOD. Our reviewer says that the requested services is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation in the medical record that alternative methods for airway clearance have been tried and failed. Specifically, there is no mention of use of a flutter valve. There is intent to prescribe nebulized saline, but no mention of whether the patient used this and whether it helped. The patient does have a daily productive cough, but no recent exacerbations of bronchiectasis.  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 HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD) (E0483).