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

We decided that the Plan does not have to pre-approve MRI, any joint of upper extremity; without contrast material(s) (CPT code 73221), for the enrollee.

You asked the Plan to pre-approve the MRI. You say that the enrollee has met the requirements for the MRI, and they have tried physical therapy. The Plan denied your request. The Plan says the records do not indicate the Giles has had a recent (within three months) six-week trial of treatment that failed to improve the symptoms.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our physician reviewer found the enrollee did not have clear signs or symptoms suggesting high likelihood of a red flag diagnosis such as a complete rotator cuff tear and the enrollee had not tried recent physical therapy (PT), or injection as required to help justify MRI at this time. Therefore, the MRI will be considered not medically necessary 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI, any joint of upper extremity; without contrast material(s) (CPT code 73221), for the enrollee.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no skilled needs at this time.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for multiplex PCR respiratory viral panel testing provided on March 8, 2021.
You asked the Plan to pay for multiplex PCR respiratory viral panel. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because the documentation indicates more than 5 targets in this panel which is non-covered.
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more targets are not covered. We looked at the file and Medicare rules. This viral panel of 6 or more targets is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of multiplex PCR respiratory viral panel have not been met. Therefore, we decided that the Plan does not have to pay for multiplex PCR respiratory viral panel testing provided on March 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 1, 2020.

You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.

The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.

We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 1, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services billed with Patient Driven
Payment Model (PDPM) code KAXE1 x 5 and provided on July 1, 2020, through July 5, 2020.
You asked the Plan to pay for the SNF services billed with PDPM KAXE1x5. You say that you would like
reconsideration because the medical records submitted support the PDPM code billed. The Plan denied your
request. The Plan says that the documentation provided does not support coding of all Section GG payment
items which results in a reduction of the PT/OT and nursing components of the validated PDPM score.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. Specifically, the record indicates that the Plan reviewed medical records to
identify inconsistencies between the clinical documentation and coding. The Plan has failed to forward medical
records for review. We are unable to determine if coding criteria have been met without medical records. It is
the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated
so we must find in your favor. Therefore, we decided that the Plan has to pay for the Skilled Nursing Facility
(SNF) services billed with Patient Driven Payment Model (PDPM) code KAXE1 x 5 and provided on July 1,
2020, through July 5, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425), provided on April 16, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that the
ambulance transport was medically necessary. The Plan denied your request. The Plan says the ambulance
transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 ambulance service, basic life support, non-emergency
transport. Our reviewer says that the ambulance transport was not medically necessary. Our
physician reviewer found that the enrollee is an 83-year-old male who was transported via ambulance from the
hospital to his residence following treatment for Coronavirus (COVID-19). He was in no distress, not on
oxygen, and able to stand and walk without assistance. The enrollee's vitals were normal.

The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi,
private car, or other type of vehicle) were contraindicated for the enrollee. The documentation does not support
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully
equipped ambulance can provide for safe transport. The documentation does not support that the ambulance
transport on April 16, 2021, was medically reasonable and necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency
transport (A0428, A0425), provided on April 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vestibular Function Testing (VEMP).

You asked the Plan to pre-approve Vestibular Function Testing (VEMP). The Plan denied your request. The Plan says vestibular function testing is considered investigational. Investigational services are not a covered benefit.

The Plan follows Medicare rules. Medicare rules say that most of the tests for vestibular function are conducted once per day. Repeat testing is only covered when medically necessary to assess specific medical or surgical treatments. In this instance, medically necessary means, for example, if symptoms are unchanged or a treatment completely resolves symptoms, elaborate repeat testing is not usually medically necessary to confirm this. 

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 Vestibular Function Testing. Our reviewer says that vestibular function testing does not meet Medicare criteria. Our physician reviewer found that you were reported to have had a left side craniotomy for repair of superior canal dehiscence. You reported some tinnitus, but no dizziness. You reported improving balance. Vestibular testing services was requested.

Vestibular testing had been performed previously in 2018 showing positive ECoG on right, normal calorics, low VEMP on left and absent VEMP on right, positive fistula test on left. The Plan rules state that "Repeat testing on a regular basis, in the absence of the resumption of symptoms, is not warranted." There was no reported worsening or recurrence of symptoms to justify repeat testing at this time. Therefore, this request for vestibular testing does not meet Medicare 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 Vestibular Function Testing have not been met. Therefore, we decided that the Plan does not have to pre-approve Vestibular Function Testing (VEMP).
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 these services are medically necessary.
The Plan denied your request. The Plan says that your records do not show that you require hospital level of
care, special nursing care, or daily doctor visits.

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. You are
receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. There are no services available
at the LTACH that you require that are not available at the health care setting being offered by the health plan.
Our physician reviewer found that your condition does not meet Medicare criteria for LTACH 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 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 the anesthesia for a patient of extreme age (99100) provided
on May 21, 2021.
You asked the Plan to pay for the anesthesia for a patient of extreme age. You say that you would like these
claims reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says
this procedure is always bundled into payment for other services not specified and no separate payment.
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 99100 is anesthesia for patient of extreme age, younger
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).
We find that CPT code 99100 is not supported in the medical record. Specifically, CPT code 99100 has a status
indicator of B meaning that payment for this service is always bundled into another procedure. Separate
payment is not made for CPT code 99100. Based on this information, we decided that Medicare rules for
coverage of the anesthesia for a patient of extreme age have not been met. Therefore, we decided that the Plan
does not have to pay for the anesthesia for a patient of extreme age (99100) provided on May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the endodontic therapy (D3330), and limited oral evaluation (D0140), provided on May 12, 2021.
You asked the Plan to pre-approve the endodontic therapy and limited oral evaluation. You say that the services should be covered. The Plan denied your request. The Plan says the mandatory supplemental dental plan does not have any out of network coverage.
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. Specifically, you received your dental services out of network.
Therefore, we decided that the Plan does not have to pre-approve the endodontic therapy (D3330), and limited oral evaluation (D0140), provided on May 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on January 4, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found the enrollee is a 67-year-old female with Parkinson's disease who was transported via ambulance for a non-emergent hospital appointment for barium swallow study. She was found in her powered wheelchair and not in any distress. The enrollee's vitals were normal. She was diagnosed with weakness and lack of coordination. She was transported via stretcher due to being too weak to sit up or brace herself in a wheelchair van. No treatment was administered during transport. The documentation does not support that other means of transport (such as stretcher van) were contraindicated for this enrollee on January 4, 2021. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport on January 4, 2021. The documentation does not support that the ambulance transport on January 4, 2021 was medically reasonable and necessary for the enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, (A0428, A0425) provided on January 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services (73130 and 73590) provided on March 7,
2021.
You asked the Plan to pay for the x-ray services. You say that you would like these claims reprocessed based
on the medical documentation. The Plan denied your request. The Plan says these claims have processed
correctly.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We find that additional units of CPT codes 73130 and 73590 are not supported in the medical record.
Specifically, the record indicates that this is an exact duplicate of another claim that has been processed and
paid. Based on this information, we decided that Medicare rules for coverage of the x-ray services have not
been met. Therefore, we decided that the Plan does not have to pay for the x-ray services (73130 and 73590)
provided on March 7, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve diagnostic cardiac catheterization for the enrollee.

You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show any symptoms, or that the enrollee is being considered for cardiac transplant or coronary bypass surgery.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 the surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee underwent coronary computed tomography (CT) scan and was found to have narrowing in several vessels, including lesions greater than 70%. Intervention would be medically reasonable even in the setting of a normal stress test. The record provided establishes the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are satisfied. 

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 surgery have been met. Therefore, we decided that the Plan has to pre-approve diagnostic cardiac catheterization for the enrollee.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve the carboplatin/pemetrexed with pembrolizumab chemotherapy
regimen.
You asked the Plan to pre-approve the requested chemotherapy regimen. You say that you would like
reconsideration because the requested regimen is medically necessary. The Plan denied your request. The Plan
says that the requested treatment is not the recommended treatment for member's condition.
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 the requested chemotherapy regimen.
Our reviewer says that the combination of carboplatin/pemetrexed with pembrolizumab is FDA approved for
the treatment of the lung as 1st line therapy in patient's without a driver mutation. Our physician reviewer
found although no PD-L1 is provided a liquid biopsy was done and there was no EGFR or ALK mutation that
were actionable. The service is reasonable and 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 the requested chemotherapy regimen have been met. Therefore, we decided that
the Plan has to pre-approve the carboplatin/pemetrexed with pembrolizumab chemotherapy regimen.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99212 provided on June 3, 2021.
You asked the Plan to pay for the office visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99212 is office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
We find that CPT code 99212 is not supported in the medical record. Specifically, the documentation shows that the services billed were provided in a clinic setting. This code cannot be billed in a clinic setting. This means that this code was billed incorrectly. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99212 provided on June 3, 2021.