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

 We decided that the Plan does not have to pay for the chest x-ray (71046) provided on June 14, 2021.  You asked the Plan to pay for the chest x-ray. The Plan denied your request. The Plan says there is no record of a requested demographic change on file from the enrollee prior to this date of service. The Plan also says that the service is not emergent in nature, there was no primary care physician referral, and the claim has processed correctly as out-of-network.  Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.    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 chest x-ray. Our reviewer says that the chest x-ray was not medically reasonable and necessary. Our physician reviewer found on exam the enrollee's lungs were clear. There was no specific clinical rationale for the requested chest x-ray. Our reviewer found that the enrollee could have foreseen requiring the services prior to leaving their service area. Our physician reviewer also found that it would have been medically reasonable to delay the services until July 31, 2021 when enrollee disenrolled from the 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 chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray (71046) provided on June 14, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 6 home health physical therapy visits.  You asked the Plan to pre-approve 6 home health physical therapy visits. 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 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 6 home health physical therapy visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 6 home health physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an advanced foot with ankle feature and the extra covering.  You asked the Plan to pre-approve an advanced foot with ankle feature and the extra covering. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan follows Medicare rules. Medicare rules say that a microprocessor controlled ankle foot system (L5973), energy storing foot (L5976), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) is covered for beneficiaries whose functional level is 3 or 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 an advanced foot with ankle feature and the extra covering. Our reviewer says that the items are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria detailed in the LCD for the advanced foot with ankle feature and the upgraded covering. Records indicate your present K3 foot is still under warranty and Medicare does not cover replacement of items that are still under warranty. Medical records from the treating provider do not document the need for the upgraded covering.  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 advanced foot with ankle feature and the extra covering have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced foot with ankle feature and the extra covering.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the manual therapy techniques (97140) rendered by the out-of-network (OON) provider on June 2, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110) and the manual therapy techniques (97140) rendered by the out-of-network (OON) provider on June 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested Intracept procedure is considered experimental in nature, as more research is needed to support efficacy. The services are therefore 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 an Intracept procedure.
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 you would prefer to be admitted to an IRF to regain your prior level of function as quickly as possible. You say you were previously independent and feel you will not reach full recovery in a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You do not have acutely complex medical diagnoses and do not require supervision by a rehabilitation physician. Your care needs can be met in an alternate setting.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a screening colonoscopy.  You asked the Plan to pre-approve the screening colonoscopy. The Plan denied your request. The Plan says this service is not medically necessary. The Plan also says that given the enrollee's two negative colonoscopies, no noted first-degree relatives with colon cancer, and vague references to a family history of polyps, the enrollee appears appropriate for routine screening every 10 years.  The Plan must follow Medicare rules. Medicare rules say that an individual at high risk for developing colorectal cancer has one or more of the following: A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; A family history of familial adenomatous polyposis; A family history of hereditary nonpolyposis colorectal cancer; A personal history of adenomatous polyps; A personal history of colorectal cancer; or Inflammatory bowel disease, including Crohn's Disease, and ulcerative colitis.   We looked at the file and Medicare rules. The record shows that the enrollee has had 2 previous colonoscopies, one in 2011 and one in 2016. No polyps were noted on either study. There are no details describing whether the enrollee's relative's polyps were adenomatous and which relatives had the polyps.     Based on this information, we decided that Medicare rules for coverage of the screening colonoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a screening colonoscopy.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes (99239) provided on April 23, 2021.  You asked the Plan to pay for hospital discharge day management of more than 30 minutes. You say that these services were billed appropriately, and medical documentation was provided to support the provided care as billed. The Plan denied your request. The Plan says there is insufficient documentation to support that this service was provided for more than 30 minutes on the date in question. However, the Plan has overturned and will cover the other services provided from April 3, 2021, to April 22, 2021.  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 99239 is hospital discharge day management, more than 30 minutes.  We find that CPT code 99239 is not supported in the medical record. Specifically, the total time for this service is not documented. A start time is documented for the assessment, but there is no end time indicated or documentation of total time. Based on this information, we decided that Medicare rules for coverage of hospital discharge day management of more than 30 minutes have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management, more than 30 minutes (99239) provided on April 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 you continue to receive acute care services, and these have not been denied. The medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility.  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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for diagnostic mammography, including computer-aided detection (CAD) when performed (77066) provided on June 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the diagnostic service. You say that this claim denied in error. This enrollee was referred by the primary care physician/office. Please see supporting documentation and reprocess your claim for payment. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 diagnostic mammography, including computer-aided detection (CAD) when performed (77066) provided on June 9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on May 11, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found that the enrollee is a 71-year-old male with a diagnosis of adjustment disorder with depressed mood. The GeneSight Psychotropic test has not been shown to be useful, and therefore is not considered medically reasonable and necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided on May 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Emsella magnetic stimulation chair.  You asked the Plan to pre-approve Emsella magnetic stimulation chair. You say that the alternative is Botox injections into your bladder which could be very expensive. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this technology is experimental/investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Emsella magnetic stimulation chair. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental/investigational and does not meet coverage criteria.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Emsella magnetic stimulation chair have not been met. Therefore, we decided that the Plan does not have to pre-approve an Emsella magnetic stimulation chair.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician's services provided on November 5, 2020.  You asked the Plan to pay for physician's services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on November 4, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services provided from September 16, 2020, to September 23, 2020.  You asked the Plan to pay for the inpatient services. You say that the diagnosis is supported by documentation. The Plan denied your request. The Plan says the documentation is incomplete regarding the assignment of J96.01.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with J96.01, defined as chronic respiratory failure, acute respiratory failure with hypoxia. 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 physician reviewer found that the enrollee was admitted to the hospital for coronary artery bypass grafting with general anesthesia. It was noted that the enrollee was extubated routinely but still required 3-4 liters of oxygen supplementation to maintain oxygen saturation of 90% for greater than 48 hours. Acute respiratory failure was listed as a secondary diagnosis. The records did not show the enrollee showed signs of respiratory distress or high flow oxygenation or prolonged intubation to support the diagnosis of acute respiratory failure with hypoxia as the post-operative recovery was typical of this procedure.   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 hospital services provided from September 16, 2020, to September 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).  You asked the Plan to pre-approve genicular RFA. You say that it is medically necessary for the enrollee to have this procedure as soon as possible. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies have not proven that genicular RFA is helpful for treatment of the enrollee's condition.  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 genicular RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found genicular nerve blocks are considered experimental/investigational in nature.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).