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

We decided that the Plan does not have to pre-approve VIA Disc allograft (CPT code 0627T) for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has severe post laminectomy pain
syndrome (condition where the patient suffers from persistent pain in the back following surgery to the back).
The Plan denied your request. The Plan says the services are considered experimental and 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 the services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found VIA disc allograft remains experimental in spinal surgery. More research is needed to show
safety and efficacy. 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 services have not been met. Therefore, we
decided that the Plan does not have to pre-approve VIA Disc allograft (CPT code 0627T) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the intravenous infusion, for therapy,
prophylaxis, or diagnosis (96365), the therapeutic, prophylactic, or diagnostic injection; each additional
sequential intravenous push of a new substance/drug (96375), the vedolizumab injection (J3380), the
methylprednisolone sodium succinate injection (J2930), and the normal saline solution infusion (J7050)
provided from June 15, 2021, through July 27, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to
the services provided.
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 20%
coinsurance for each Medicare-covered Part B drug.
You have been asked to pay $3,510.69 for the Medicare-Part B drugs infusions/injections provided. This
amount includes the Plan allowed amount of $13,330.96 x 20% coinsurance = $2,666.18 for dates of service
June 15, 2021, through June 29, 2021. Additionally, this amount includes $844.51 for date of service July 27,
2021, which is less than the applicable coinsurance as you had met the in-network out-of-pocket maximum for
the 2021 calendar year. 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 coinsurance for the intravenous infusion, for
therapy, prophylaxis, or diagnosis (96365), the therapeutic, prophylactic, or diagnostic injection; each
additional sequential intravenous push of a new substance/drug (96375), the vedolizumab injection (J3380), the
methylprednisolone sodium succinate injection (J2930), and the normal saline solution infusion (J7050)
provided from June 15, 2021, through July 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nurtec.
You asked the Plan to pre-approve Nurtec. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Nurtec.
Benefits for Nurtec 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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. The patient was admitted for an iliopsoas tear. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 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 IRF admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the excision of a tumor, soft tissue of foot or toe, subcutaneous (28039) provided on April 27, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $300 copayment for each Medicare-covered outpatient surgery at an ambulatory surgical center or outpatient hospital.
You have been asked to pay a $300 copayment for the Medicare-covered outpatient surgery provided at an ambulatory surgical center. 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 the excision of a tumor, soft tissue of foot or toe, subcutaneous (28039) provided on April 27, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive medication services (H2010), comprehensive community support services (H2015) and family consultation (90887) provided on November 10, 2020, through January 5, 2020.
You asked the Plan to pay for the comprehensive medication services, comprehensive community support services and family consultation. You say that you would like reconsideration because these services are medically necessary. The Plan denied your request. The Plan says the codes billed are not valid for Medicare purposes.
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 H2015, H2010 and 90887 are not supported in the medical record. Specifically, CPT codes H2015 and H2010 have a status indicator of I. This means that these codes are not valid for Medicare purposes. CPT code 90887 has a status indicator of B. This means that payment for CPT code 90887 is always bundled into the payment for another service. Based on this information, we decided that Medicare rules for coverage of the comprehensive medication services, comprehensive community support services and family consultation have not been met. Therefore, we decided that the Plan does not have to pay for the comprehensive medication services (H2010), comprehensive community support services (H2015) and family consultation (90887) provided on November 10, 2020, through January 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant care services (S5125).
You asked the Plan to pre-approve attendant care services. You say that you need 24-hour care. The Plan denied your request. The Plan says this request does not meet the Medicare or health plan coverage criteria.
The Plan must follow Medicare rules. The rules say that home health aide (HHA) services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 attendant care services. Our reviewer says that home health aide (HHA) services are not shown to be medically necessary, reasonable or coverable. Our physician reviewer found you do not have documented skilled nursing needs. Our reviewer also found that you do not have documented skilled therapy needs.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of attendant care services have not been met. Therefore, we decided that the Plan does not have to pre-approve attendant care services (S5125).
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 that the enrollee is an 80-year-old female with a past medical history of hypertension, hypothyroidism and degenerative disc disease who presented to the acute hospital on October 27, 2021, with a fall and left hip and back pain. While the enrollee does require skilled therapy services, there is no documentation that the patient requires skilled nursing services. In addition, daily skilled services are not required. In conclusion, the enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case.

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).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services (procedures codes 80307 and G0483)
provided to the enrollee on April 15, 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 denied codes remain not supported.
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 the denied codes is:
CPT 80307:
Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument
chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]),
chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART,
DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when
performed, per date of service
Healthcare Common Procedure Coding System (HCPCS) G0483: Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed We find that CPT code 80307 and HCPCS G0483 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services (procedures codes 80307 and G0483) provided to the enrollee on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the office services. You say that you have a rare disease called Conns Syndrome and there is no specialist of this kind in you are. The Plan denied your request. The Plan says there are two (2) in-network providers within a 20-mile radius of your zip code.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network provider.
You asked the Plan to pre-approve SNF care. You say that the enrollee was accepted by Mountain View in Marysville, but you would like to have the enrollee admitted into Covenant Shores in Mercer Island. You state that that Mountain View is approximately 34 miles away from you versus Covenant Shores, which is only about 7 miles away. You state that in preparation after hospital and SNF discharge, you have already made arrangements to have the enrollee move to Covenant Shores Assisted Living Facility. The Plan denied your request. The Plan says the provider listed is not the enrollee's network. The Plan states the enrollee's provider did not provide records that show the enrollee has a medical need to get care outside of the enrollee's 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. Convenience of proximity to the enrollee's son during a limited and short SNF rehabilitation period, e.g., a few weeks, is not considered a medically necessary reason to authorize care at a non-network facility for the
enrollee's health plan. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve SNF care to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient psychiatric facility.

You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied
your request. The Plan says if you have not yet been discharged from the hospital, outpatient treatment can be
approved.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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
the requested admission is not medically reasonable or necessary. Our physician reviewer found based on the
records provided, it was not expected that you would improve in a reasonable period of time for the dates in
question. You have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. You
were compliant with treatment while not showing any acute threats to safety. It did not appear medically
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a
lower level of care beyond the dates in question, as you did not have dangerousness to self or others. The health
plan's denial of continued inpatient psychiatric services is appropriate.

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 an inpatient psychiatric facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on May 11, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for the OON services. You say that the test provides valuable information for physicians. The Plan denied your request. The Plan says the services were not authorized.

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 referring provider 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 lab services provided on May 11, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the facet joint injections provided on April 1, 2021.

You asked the Plan to pay for the injections. The Plan denied your request. The Plan says this is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that facet joint injections are covered for the indications established in the applicable LCD. 

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 injections. Our reviewer says that the requested facet joint injections are not medically reasonable and necessary. Our physician reviewer found that there is no numeric pain score at baseline and after the diagnostic facet injections. The undated lumbar MRI scan shows a significant non-facet pain generator (left L3-4 postero-lateral disc extrusion), and the enrollee has not tried/failed recent adequate conservative care such as physical therapy treatment. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for the facet joint injections provided on April 1, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that you need continued therapy and pain management before discharge home to an assisted living facility. The Plan denied your request. The Plan says that your needs can be safely and better managed in a less restrictive setting.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services