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

We decided that the Plan does not have to pay for autonomic function testing provided to the enrollee on February 9, 2021.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that in this case, the enrollee has a presentation of a large fiber neuropathy in the setting of multiple medical issues. He has no symptomatology to suggest the presence of a primary autonomic neuropathy or autonomic disorder. As such testing would not be indicated. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for autonomic function testing provided to the enrollee on February 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services represented by codes 97530, 97112, and 97110 provided from September 29, 2020 to October 14, 2020.

You asked the Plan to pay for codes 97530, 97112, and 97110. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. 

We find that codes 97530, 97112 and 97110 are not supported in the medical record. Specifically, the records indicate that the services were performed by a physical therapist in a home health or hospice setting. There is a more appropriate code for the billed services provided in a home health setting. Therefore, we decided that the
Plan does not have to pay for the therapy services represented by codes 97530, 97112, and 97110 provided from September 29, 2020 to October 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Kanjinti for the enrollee.

You asked the Plan to pre-approve the drug]. You say that this is medically necessary. The Plan denied your request. The Plan says studies have not proven that this drug is helpful for treatment of the enrollee's condition.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 drug]. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the use of this drug is not FDA-approved for the enrollee's diagnosis. The use of this drug is not supported by any of the major drug compendia, or by clinical research that appears in an approved medical journal. 

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 drug] have not been met. Therefore, we decided that the Plan does not have to pre-approve Kanjinti for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 25, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 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 the laboratory services provided on October 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that brain PET is covered for specific indications only. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee does not currently meet diagnostic criteria for Alzheimer's dementia or fronto-temporal dementia. There is also no documentation that she needs testing to differentiate between the two syndromes. The criteria for coverage are not met and the PET scan is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a transcutaneous Electrical Nerve Stimulation (TENS) device
and/or supplies, a pneumatic compression vasopneumatic device, multivitamin injections (compounded Nutria)
into the nerve and musculoskeletal structures provided on March 31, 2021.

You asked the Plan to pay for a TENS device and/or supplies, a pneumatic compression vasopneumatic device,
multivitamin injections (compounded Nutria) into the nerve and musculoskeletal structures. You say that the
items and services were provided, and payment should be rendered. The Plan denied your request. The Plan
says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. 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 a TENS device and/or supplies, a pneumatic
compression vasopneumatic device, multivitamin injections (compounded Nutria) into the nerve and
musculoskeletal structures. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the TENS device including supplies is not
a Medicare covered benefit with the enrollee's diagnoses. Pneumatic compression vasopneumatic devices can
be covered in the home or other outpatient setting only for the treatment of chronic venous insufficiency with
venous stasis ulcers, and refractory lymphedema. Vitamin injections into the nerve and musculoskeletal
structures are not a Medicare covered service. The review has determined that the items/services at issue in this
case are not medically reasonable or 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 TENS device and/or supplies, a pneumatic compression vasopneumatic
device, multivitamin injections (compounded Nutria) into the nerve and musculoskeletal structures have not
been met. Therefore, we decided that the Plan does not have to pay for a transcutaneous Electrical Nerve
Stimulation (TENS) device and/or supplies, a pneumatic compression vasopneumatic device, multivitamin
injections (compounded Nutria) into the nerve and musculoskeletal structures provided on March 31, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac evaluation provided on February 28, 2021 by an
out-of-network (OON) provider.
You asked the Plan to pay for the cardiac evaluation. You say that the services were rendered in good faith.
The Plan denied your request. The Plan says this provider was not in 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 pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the cardiac evaluation provided on February 28,
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 somatosensory testing (95938), needle electromyography
(95870), and continuous intraoperative neurophysiology monitoring (G0453) provided on March 2, 2021 billed
with the diagnosis code M48.04.
You asked the Plan to pay for somatosensory testing, needle electromyography, and continuous intraoperative
neurophysiology monitoring billed with the diagnosis code M48.04. You say that the services were billed
correctly, and payment should be rendered. The Plan denied your request. The Plan says diagnosis code
M48.04 is invalid.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Procedures
should be reported with the Current Procedural Terminology (CPT) code that describes the services performed.
We asked our coding 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 somatosensory testing, needle
electromyography, and continuous intraoperative neurophysiology monitoring billed with the diagnosis code
M48.04. Our reviewer says that the services do not meet billing criteria. Our coding reviewer found the
medical records and billing records note Diagnosis code M48.04 was submitted on the billed claim with 95938
and G0453. Per Articles Article - Billing and Coding: Intraoperative Neurophysiological Testing (A56722)
Article - Billing and Coding: Neurophysiology Evoked Potentials (NEPs) (A56773) diagnosis code M48.04 is
not an approved diagnosis code, therefore, these services are not eligible for reimbursement consideration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of somatosensory testing, needle electromyography, and continuous intraoperative
neurophysiology monitoring billed with the diagnosis code M48.04 have not been met. Therefore, we decided
that the Plan does not have to pay for somatosensory testing (95938), needle electromyography (95870), and
continuous intraoperative neurophysiology monitoring (G0453) provided on March 2, 2021 billed with the
diagnosis code M48.04.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from April 6, 2021 to May 5, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says a SNF admission is not medically necessary.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing or skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does 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 services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from April 6, 2021 to May 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that the enrollee has diabetes mellitus. The Plan denied your request. The Plan says that the patient is not using insulin 3 or more times per day with adjustments.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.

You asked the Plan to pre-approve acute inpatient hospital care. You say that you are appealing with
supporting records. The Plan denied your request. The Plan says the denial of authorization for inpatient level
of care is correct, because the enrollee does not meet inpatient criteria.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient level of care are met in this
case.

Our physician reviewer found based on the emergency department workup showing the main cause of the
enrollee's symptoms being uncontrolled tachycardia which required medical treatment with normal vitals
otherwise, it was expected that the enrollee would require hospital services not likely to span at least 2
midnights.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 27,
2021, to February 25, 2021.
You asked the Plan to pay for SNF care. You say that the services are necessary. The Plan denied your request.
The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 pay for SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled
nursing or therapy services on a daily basis. This beneficiary does 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pay for skilled nursing facility (SNF) care provided from January 27, 2021, to February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.

You asked the Plan to pre-approve Intracept. You say that Intracept is medically necessary for the enrollee. The
Plan denied your request. The Plan says the denial of authorization for this service is correct, because studies
have not proven that this is helpful for treatment of the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Intracept. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure is still considered experimental/investigational.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Intracept have not been met. Therefore, we decided that the Plan does not have
to pre-approve the Intracept procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) provided to you on March 16,
2021.

You asked the Plan to pay for the EKG. You say that your doctor said that this test was routine to the wellness
exam. The Plan denied your request. The Plan says you are responsible for a copayment of $30.00.

The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay $30.00 copayment for Medicare-covered non-radiological diagnostic
services.

For March 16, 2021 the provider billed service 93000 in the amount of $142.00 and the allowed amount was
$15.73. You are responsible for a cost share amount of $15.73 for this service. As the allowed amount of
$15.73 was less than the copayment amount of $30.00 you were only assessed a copayment of $15.73.

The cost-share is calculated by taking the Medicare-allowed amount and subtracting the plan paid amount and
the sequestration/discount amount. In this case, $15.73 Allowed amount - $0.00 Plan paid- $0.00 sequestration
= $15.73 Cost-Share Due. Cost-sharing is a contractual obligation and cannot be waived.

You have been asked to pay $15.73 as this this was the allowed amount and it was less than the $30.00
copayment for the EKG. The EKG falls within the Medicare-covered non-radiological diagnostic services
benefit category. 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 pay for the electrocardiogram (EKG) provided to you on
March 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on October 6, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on October 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye refraction provided by your doctor on May 4, 2021.
You asked the Plan to pay for the eye refraction. You say that you haven't had to pay for this service before.
The Plan denied your request. The Plan says the Evidence of Coverage rules say that the eye refractions must
be performed by EyeQuest to meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that that eye refraction during a routine exam are
covered services when they are performed by an EyeQuest routine vision care provider. Your eye refraction
test was not performed by EyeQuest.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for
eye refraction provided by your doctor on May 4, 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 the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. 
 
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.