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

 We decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen.  You asked the Plan to pre-approve the CT scan. You say that the records provided support the need for the requested CT scan. The Plan denied your request. The Plan says the requested CT scan is not supported because it has not been three to six months since the enrollee's lesion was found.  The Plan must follow Medicare rules. Medicare rules say that CT 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 the CT scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found no alpha fetoprotein elevation was provided, nor is there evidence that enrollee's liver disease is now decompensated to warrant consideration of liver transplantation. She has no ascites, and no splenomegaly. The urgency to recheck her liver by triple phase CT imaging now is not apparent from available records. It appears the timing of requested triple phase CT abdominal imaging is scheduled for her convenience, based on a provider note that states she is having lung cancer screening with CT of the chest on November 1, 2021, so another CT 3-phase abdomen was ordered to be added to the CT of the chest. The 4-week timeframe for this proposed study does not meet guidelines that benefit the enrollee's circumstance for a 3-6-month re-imaging interval for her subcentimeter Li-RADS 3 lesions.  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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) of the abdomen.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF) beyond 11/26/21 for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is no longer making gains in progress with therapy.  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 services. Our reviewer says that the requested continuation of services is not medically reasonable or necessary. Our physician reviewer found the enrollee no longer qualifies for SNF coverage, as there are no documented skilled nursing or skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of care, such as long-term care.  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 continued admission to a skilled nursing facility (SNF) beyond 11/26/21 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap provided on April 30, 2021.  You asked the Plan to pay for the muscle, myocutaneous, or fasciocutaneous flap. You say that fully abstracted notes are attached that fully support separate reimbursement and the claim should be reviewed for additional payment. The Plan denied your request. The Plan says procedure code 15733 is inclusive to procedure code 61512.  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 15733 is muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (i.e., buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae).  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the muscle, myocutaneous, or fasciocutaneous flap. Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the documentation does not include enough detail to confirm pericranial graft is a separate identifiable procedure from approved CPT code 61512. Therefore, CPT code 15733 would not be reported separately.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the muscle, myocutaneous, or fasciocutaneous flap have not been met. Therefore, we decided that the Plan does not have to pay for the muscle, myocutaneous, or fasciocutaneous flap provided on April 30, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 11, 2021.  You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan denied your request. The Plan says the enrollee was enrolled in Hospice during the time of service.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 11, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the inpatient services provided October 21, 2020 to December 2, 2020.  You asked the Plan to pay for the inpatient services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not payable.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also 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.  We find that the inpatient services are supported in the medical record. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan has stated that they have overturned some of the inpatient services for dates of service from October 21, 2020 to December 2, 2020; however, the Plan did not specify what dates of service were covered. In addition, the Plan states that some of the services billed were unbundled and were inclusive to either room and board or the procedure charge; however, the Plan did not specify which CPT codes were being denied due to unbundling. The Plan did not substantiate their denial. Based on this information, we decided that Medicare rules for coverage of the inpatient services have been met. Therefore, we decided that the Plan has to pay for the inpatient services provided October 21, 2020 to December 2, 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (0012M) provided April 23, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare has re-affirmed non-coverage for procedure codes 0012M and 0013M for Cxbladder.  We looked at the file and Medicare rules. At issue is CxBladder testing. This procedure is non-covered under Medicare. 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 lab services (0012M) provided April 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the extractions (D7210) for teeth #s 14, 18, 20, 21, 29, and 30, and the collection and application of autologous blood concentrate product (D7921) provided on May 26, 2021.  You asked the Plan to pay for the dental services. You say that you had part of your lower left jaw removed. You say that you had 6 teeth removed that were affected by your jaw dying. You also say that you should be reimbursed for these services. The Plan denied your request. The Plan says routine dental services are not covered by Medicare.  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 dental services. Our reviewer says that the dental services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the provided documentation does not indicate what the primary condition was specifically and what portions of the jaw were involved. The reviewer found that the specifics of the treatment and final diagnosis is critical to being able to determine which, if any, tooth removal were associated with a medical condition that required such removal. Given the supplied records, the determination cannot be made that the criteria would be met to allow for coverage of tooth removal under the limited circumstances that would allow for it.  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 dental services have not been met. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the extractions (D7210) for teeth #s 14, 18, 20, 21, 29, and 30, and the collection and application of autologous blood concentrate product (D7921) provided on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0669) for the enrollee.  You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there are no objective measurements to support the presence of abdominal, chest, and/or truncal lymphedema.  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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence of lymphedema of the chest, trunk, or abdomen on the treating medical provider nurse practitioner or physician medical progress notes. There are no unique characteristics that would indicate the segmented pump over a standard pump on the submitted documentation. The documentation does not reveal a four-week trial of the standard pump. The criteria for E0652 segmental pneumatic compression device and CPT code E0669 - segmental pneumatic appliance for use with pneumatic compressor, half leg have not been met.  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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0669) for the enrollee.
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 these services are medically necessary. The Plan denied your request. The Plan says that the services you require can safely be received at a different 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 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 skilled nursing facility (SNF) 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 you are unsatisfied with the general care being provided at your current facility and feel you would benefit from a more aggressive therapy program. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. It is anticipated that you will continue to demonstrate rapid recovery as your endurance and activity tolerance improves through skilled therapy at the current skilled nursing facility. Your needs do not require IRF care.  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 with your current medical stability and lack of medical complexity, there is no need for physician supervision three times per week for the ongoing management of any active or acute exacerbations of chronic medical conditions. You do not have acute nursing care needs. Based upon your current level of function, you do not require intensive therapies, consisting of at least 3 hours of therapy at least 5 days per week with a multidisciplinary approach to daily therapy. You do need continued physical and occupational therapy, but these services can be provided in an alternate and low intensity level. IRF admission is not reasonable or medically necessary in this case. Your rehab needs can be safely continued in the current skilled nursing facility or at home post-discharge.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve neuropsychological testing for the enrollee.  You asked the Plan to pre-approve the testing. You say that this is medically necessary for annual reevaluation of cognitive functioning. The Plan denied your request. The Plan says routine follow-up is not listed as a valid indication.  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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation shows that the enrollee was pleasant and feeling much better. There was no documentation of a decline in memory and functional ability since the last visit. The enrollee had previous neuropsychological testing performed on April, 2019 which indicated cognitive in efficiencies primarily involving attention, processing speed and executive function. Therefore, the enrollee does not meet the criteria for neuropsychological testing, as it does not appear medically reasonable to repeat the testing without a clear indication as to how the recommendations would be any different from what was previously given in the prior testing.  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 pre-approve neuropsychological testing for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the CxBladder testing provided on May 7, 2021.  You asked the Plan to pay for the testing services. You say that the test improves the enrollee's compliance with accurate, non-invasive testing. The Plan denied your request. The Plan says the test is not approved.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    We find that the testing at issue is not supported in the medical record. Specifically, the ordering provider did not demonstrate that the use of biomarkers will be used to assist in the management/treatment of the enrollee. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on May 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine vision services provided on August 6, 2021.  You asked the Plan to pay for the services provided. You say that your insurance has paid for your eye exams every year. The Plan denied your request. The Plan says you do not have out-of-network benefits.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.   We looked at the file and the Plan's rules. The provider in this case is not a network provider with your routine vision plan. Your plan only covers routine vision care from network providers. Based on this information, we decided that the Plan's rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the routine vision services provided on August 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that intensive inpatient therapy services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.  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. 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 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.