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

We decided that the Plan does not have to pay for diagnostic radiology services provided on February 17, 2021.
You asked the Plan to pay for diagnostic radiology services. The Plan denied your request. The Plan says Original Medicare pays claims for Medicare-covered non-hospice services provided by physicians, providers or suppliers. Original Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice election has been revoked or terminated.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 1, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for diagnostic radiology services provided on February 17, 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 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from additional physical and occupational therapy but the documentation does not reveal that this therapy must be only on an intensive level 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from February 5, 2021, to March 2, 2021.

You asked the Plan to pay for home health services. The Plan denied your request. The Plan says services were not billed with an appropriate code.

The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. 

We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim does not show that a Q code was billed for the services at issue. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 5, 2021, to March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.

You asked the Plan to pre-approve bone marrow aspirate. 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. 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 bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition as discussed above. Therefore, the request for bone marrow aspirate is 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 35 hours per week of services of a home health aide (HHA) (G0156) and direct skilled nursing services of a registered nurse (RN) (G0299).
You asked the Plan to pre-approve the 35 hours per week of HHA services and skilled nursing services of a RN. You say that you are concerned that your HHA hours were reduced. You also say that you need more hours because you have pain in your entire body, cannot hold anything in your right hand, and it is very difficult to do everyday activities at home due to your medical conditions. The Plan denied your request. The Plan says you meet the guidelines for 12 hours of a HHA per week, but not 35 hours per week.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 35 hours per week of HHA services and skilled nursing services of a RN. Our reviewer says that there is no documentation that the additional nursing services requested (beyond what the health plan has already approved) meet Medicare criteria for medical necessity. Our physician reviewer found there is no documentation that the additional nursing services requested (beyond what the health plan has already approved) meet Medicare criteria for medical necessity. Our reviewer also found that there is no documentation that the additional nursing services requested (beyond what the health plan has already approved) meet the definition of home health aide services as per Sections A, B, C, D & E of Section 50.2. 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 35 hours per week of HHA services and skilled nursing services of a RN have not been met. Therefore, we decided that the Plan does not have to pre-approve 35 hours per week of services of a home health aide (HHA) (G0156) and direct skilled nursing services of a registered nurse (RN) (G0299).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found you are receiving appropriate care at the present acute care hospital. There are no
services available at the LTACH that you require that are not available at the health care setting being offered
by the health plan.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a duplex scan of upper extremity arteries or arterial bypass grafts.
You asked the Plan to pre-approve a duplex scan of upper extremity arteries or arterial bypass grafts. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that duplex scanning may be of value in the evaluation of an abdominal aortic aneurysm. 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 duplex scan of upper extremity arteries or arterial bypass grafts. Our reviewer says that the services are medically necessary. Our physician reviewer found the discordant blood pressures between the right lower extremity and both upper extremities need to be explained. The blood pressures obtained amount to an abnormal Ankle brachial index although inversely so compared to the usual scenario where the low pressure is in the lower extremity. It is reasonable to investigate the cause of this discordance and the use of bilateral upper extremity duplex scanning is noninvasive and will provide the information desired. 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 duplex scan of upper extremity arteries or arterial bypass grafts have been met. Therefore, we decided that the Plan has to pre-approve a duplex scan of upper extremity arteries or arterial bypass grafts.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an emergency room visit (99285) provided on June 22, 2021.
You asked the Plan to pay for an emergency room visit. You say that this was billed with the correct diagnoses. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that when coding an adverse effect of a drug that has been correctly prescribed and properly administered, assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50). We looked at the file and Medicare rules. The primary, first-billed diagnosis on this claim is T50.905A, adverse effect of unspecified drugs, medicaments and biological substances, initial encounter. Coding guidelines require the nature of the adverse effect to be listed before this code. Based on this information, we decided that Medicare rules for coverage of an emergency room visit have not been met. Therefore, we decided that the Plan does not have to pay for an emergency room visit (99285) provided on June 22, 2021
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PR F2 gene analysis 20210G >A variant.

You asked the Plan to pre-approve PR F2 gene analysis 20210G >A variant. 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 follows Medicare rules. Medicare rules say that genetic testing for these genes for all risk factors, signs, symptoms, diseases, or conditions, including cardiovascular risk assessment, are non-covered except for pregnant patients. 

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 PR F2 gene analysis 20210G >A variant. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested service is excluded from coverage under the elements of the local coverage criteria. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PR F2 gene analysis 20210G >A variant have not been met. Therefore, we decided that the Plan does not have to pre-approve PR F2 gene analysis 20210G >A variant.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement provided on July 17, 2021 by an out-of-network (OON) provider.
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 rendered by an out-of-network provider without prior authorization.
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 debridement provided on July 17, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight Psychotropic test provided to the enrollee on August 26, 2021.
You asked the Plan to pay for the test. You say that this should be paid for. The Plan denied your request. The Plan says this testing has not been shown to be useful, medically necessary, or appropriate.
The Plan must follow Medicare rules. Medicare rules say that the current evidence does not support the use of GeneSight testing. Medicare does not currently consider the denied testing to be reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the test have not been met. Therefore, we decided that the Plan does not have to pay for the GeneSight Psychotropic test provided to the enrollee on August 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction of paravertebral facet joint nerves.
You asked the Plan to pre-approve destruction of paravertebral facet joint nerves. 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 follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary when specific 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 pre-approve destruction of paravertebral facet joint nerves. Our reviewer says that the services are not medically necessary. Our physician reviewer found the LCD
requires repeat diagnostic medial branch block (MBB) if more than 2 years have elapsed since the last radiofrequency ablation (RFA). Therefore, at this point, the request is deemed 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 destruction of paravertebral facet joint nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction of paravertebral facet joint nerves.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99307) provided on July 14, 2021 to July 30, 2021.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were non-emergent and were not pre-approved.
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 services at issue in this appeal. The Plan did not pre-approve the service
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 physician services (99307) provided on July 14, 2021 to July 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. 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. 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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not state that the enrollee is not indicated for operative intervention at no more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the $150 copayment charged for shoulder surgery provided on
February 10, 2021.

You asked the Plan to waive this copayment. You say that you cannot afford this bill. The Plan denied your
request. The Plan says this copayment was charged based on the claim submitted by the provider and your Plan
contract agreement. The Qualified Independent Contractor overturned the Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct contract language.

The Plan is correct in this case. 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 $150 copayment for outpatient surgical services. 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 $150
copayment charged for shoulder surgery provided on February 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (88121) provided July 16, 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 the tests were performed for screening purposes and are non-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, Urovysion, 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 lab services (88121) provided July 16, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on May 1, 2021.
You asked the Plan to pay for the non-emergency transportation, wheelchair van. You say that you were told that your family could not handle you because of your medical condition and dementia diagnosis, so you were transported. The Plan denied your request. The Plan says experimental services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on May 1, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for portable x-ray transportation (R0070) provided June 18, 2021.
You asked the Plan to pay for the portable x-ray transportation. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 CPT code R0070 is not supported in the medical record. Specifically, the x-ray transportation code was billed without the required setup code. Based on this information, we decided that Medicare rules for coverage of the portable x-ray transportation have not been met. Therefore, we decided that the Plan does not have to pay for portable x-ray transportation (R0070) provided June 18, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87500, 87798, 87799, 87640, 87653, 87482) provided July 21, 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 the services were performed for screening purposes and are non-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, genetic testing, 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 lab services (87500, 87798, 87799, 87640, 87653, 87482) provided July 21, 2021.