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

 We decided that the Plan does not have to pay for the anesthesia (01400), injections (64447 and 64450) and ultrasonic guidance for needle placement (76942) provided on July 22, 2021.  You asked the Plan to pay for the anesthesia, injections, and ultrasonic guidance. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services 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 01400 is anesthesia for open or surgical arthroscopic procedures on knee joint; not otherwise specified.   The CPT Code Manual definition of code 64447 is  injection(s), anesthetic agent(s) and/or steroid; femoral nerve.  The CPT Code Manual definition of code 76942 is ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation.  The CPT Code Manual definition of code 64450 is  injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch.  We find that CPT codes 01400, 64447, 76942 and 64450 are not supported in the record. Specifically, the documentation submitted does not include any clinical information or medical records to verify the services that have been billed. There is insufficient information to determine if Medicare criteria for coverage have been met. Based on this information, we decided that Medicare rules for coverage of the anesthesia, injections and ultrasonic guidance have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia (01400), injections (64447 and 64450) and ultrasonic guidance for needle placement (76942) provided on July 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a patient lift and associated supplies (E0630, A9270, E0621) provided from April 27, 2020, through April 29, 2020.

You asked the Plan to pay for a patient lift and associated supplies. You say that this equipment was medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage was not met for this equipment when it was ordered.

The Plan must follow Medicare rules. Medicare rules say that a patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined. 

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 patient lift and associated supplies. Our reviewer says that the ordered patient lift was not medically necessary. Our physician reviewer found that the criteria for coverage had not been met at as the medical documentation that was submitted did not indicate that without the use of a lift, the patient would have been bed confined. As the patient lift is not covered, the associated equipment will be denied as also not 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 a patient lift and associated supplies have not been met. Therefore, we decided that the Plan does not have to pay for a patient lift and associated supplies (E0630, A9270, E0621) provided from April 27, 2020, through April 29, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for SelectMDx testing (81479) provided on March 12, 2021.  You asked the Plan to pay for SelectMDx testing. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that code 81479 is not considered medically necessary when used for SelectMDx.  We looked at the file and Medicare rules. The testing at issue is not covered. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Based on this information, we decided that Medicare rules for coverage of SelectMDx testing have not been met. Therefore, we decided that the Plan does not have to pay for SelectMDx testing (81479) provided on March 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you would benefit from short-term rehabilitation to become stronger. The Plan denied your request. The Plan says the enrollee does not meet the criteria for swing bed/SNF coverage.

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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for air ambulance services provided on November 11, 2019.  You asked the Plan to pay for air ambulance services. The Plan denied your request. The Plan says there was no medical indication for the member to be transported home via air transportation.  The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   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 air ambulance services. Our reviewer says that the air ambulance services were not medically necessary. Our physician reviewer found that there was no medical indication for you to be transported home via air transportation. You were receiving appropriate medical care at the hospital in Vancouver and your family elected to transport you home on their own. You were receiving the same level of care at the hospital in Vancouver as you would receive in the United States. The review has determined that the documentation did support that you suffered from an illness or injury that contraindicated transportation by any means other than ambulance. The documentation did not support that your condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to your survival or seriously endangered your health. The documentation did not support that the transferring hospital did not have adequate facilities to provide the medical services you needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance services provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for vitamin D lab assay (82306) thromboplastin time, partial (85730), provided June 17, 2021.  You asked the Plan to pay for the outpatient services. You say that you request review of medical necessity for these outpatient services and prompt payment of this claim. The Plan denied your request. The Plan says missing or invalid diagnosis code. Screening testing is not a Medicare benefit.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the outpatient services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for vitamin D lab assay (82306) thromboplastin time, partial (85730), provided June 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 11, 2021, and the inpatient hospital services you received from July 11, 2021, to July 14, 2021.  

You asked the Plan to waive the copayment for the ER visit and the inpatient hospital services. You say that you were charged for services you did not have. You said that you did not have any physical therapy or computed tomography (CT) scans while you were in the hospital. The Plan denied your request. The Plan says you were charged this copayment correctly.  

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $250 copayment per day for days 1-7 for inpatient hospital care.   

Records show that you were in the ER on July 11, 2021, and then admitted to the hospital for three days from July 11, 2021, to July 14, 2021. You have been asked to pay a $90 copayment for the ER visit and a $250 copayment for each of the three days of the inpatient stay, for a total of $840.  This inpatient copayment is a per-day copayment and applies regardless of the extent of services you receive while you are an inpatient. 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 emergency room (ER) visit you had on July 11, 2021, and the inpatient hospital services you received from July 11, 2021, to July 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.  We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on February 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory testing (CPT code 0012M) provided on January 12, 2021.  

You asked the Plan to pay for the laboratory testing. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says your request is not a covered benefit because this test has been determined not to be clinically valid and is a non-covered test.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory testing have not been met. The rules say non-coverage reaffirmed for CPT codes 0012M and 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for the laboratory testing (CPT code 0012M) provided on January 12, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Orencia (J0129).  You asked the Plan to pre-approve Orencia. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says step therapy rules for the requested treatment have not been met.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Orencia. Our reviewer says that the requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the Plan requires a trial of drugs Remicade, Infliximab, Inflectra, or Simponi Aria before they will approve the requested drug. The clinical documentation in the case record does not support that Remicade, Infliximab, Inflectra, or Simponi Aria have been tried and failed. The documentation does not support that Remicade, Infliximab, Inflectra, or Simponi Aria would likely be less effective and/or would likely have adverse effects for the enrollee 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Orencia (J0129).
Appeal type: Practitioner Services
Decision: Favorable

 We decided that the Plan has to pay for a group 2 power wheelchair (K0835).  You asked the Plan to pay for the power wheelchair. The Plan denied your request. The Plan says that this is not medically necessary.  The Plan follows Medicare rules. Medicare rules say that a group 2 power wheelchair is covered when the applicable LCD coverage criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the power wheelchair. Our reviewer says that the requested group 2 power wheelchair is medically reasonable and necessary in this case. Our physician reviewer found that the enrollee has a neurologic disorder with functional deficits. She meets criteria for use of a power mobility device.  The mobility evaluation supports that she requires a power mobility device to accomplish mobility-related activities of daily living in the home and that she is capable of using one safely.  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 power wheelchair have been met. Therefore, we decided that the Plan has to pay for a group 2 power wheelchair (K0835).   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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genioplasty/lower chin surgery.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered cosmetic.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    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 surgery is not medically reasonable or necessary. Our reviewer found that in this case, the record indicates that the enrollee has obstructive sleep apnea is undergoing surgical intervention. The record provided does not indicate that the enrollee has had an accidental injury or that the procedure will improve the function of a malformed body part. The record indicates that the enrollee has stated that the requested procedure is for appearance. The records provided are insufficient to determine whether 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 not been met. Therefore, we decided that the Plan does not have to pre-approve genioplasty/lower chin surgery.
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 enrollee has a broken hip and needs to be monitored for their wound vac and magnesium. The Plan states the enrollee is unable to walk or live independently until they get better and has low magnesium levels that need to be monitored. The Plan denied your request. The Plan says the enrollee clearly requires physical and occupational therapy as well as pain control with medicine by mouth and management of the medicines the routinely takes every day by mouth. The Plan states the enrollee does not need to be seen by a rehabilitation doctor at least three (3) times a week for evaluation of functional and medical goals and progress and they do not need an intensive team (rehabilitation doctor and nurse, social worker, and therapists) for the enrollee's care. The Plan states it is not medically reasonable to expect the enrollee to participate in and thus benefit from, daily intensive therapies. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing 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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute IRF admission and services.
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 requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the requested IRF care have not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a PET scan.  You asked the Plan to pre-approve a PET scan. You say that  The Plan denied your request. The Plan says the office note did not report history of cancer. The office note did not report chemotherapy treatment. The office note did not report radiation treatment.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a PET scan. Our reviewer says that a PET scan is not medically necessary. Our physician reviewer found that the enrollee has no history of cancer or suspected cancer.          We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan.