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

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.  You asked the Plan to pre-approve the MRI. You say that the enrollee has had persistent right upper quadrant pain. You say that the enrollee requires an MRI for further diagnostic testing to rule out a hepatic ductal stone which would change the treatment plan going forward. You say that MRI imaging is being ordered to try and avoid another emergency room visit. The Plan denied your request. The Plan says the requested MRI is not medically necessary in the enrollee's clinical scenario and would be considered a duplicative service and not the standard of care.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the computed tomography results as described are commonly seen post-cholecystectomy and were discounted as of doubtful significance by the provider who now requests MRI. No laboratory study results, nor ultrasound were provided. No pre-cholecystectomy imaging for comparison was provided, other than allusion to a comparison CT from 2006. No gastrointestinal consultation nor endoscopic evaluation has been provided. Without the above clinically appropriate results the medical necessity for MRI imaging is not supported at this juncture based on available records.  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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the abdomen.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing (CPT code(s): 81404, 81405, and 81046) provided to the enrollee on December 22, 2020.  You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered as billed.  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.  Review of the file shows that the enrollee had genetic cardiovascular risk assessment testing on December 22, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular genetic risk assessment panels. Medicare only covers a lipid panel consisting of a total cholesterol, HDL cholesterol, and triglyceride once every five (5) years as cardiovascular screening. Therefore, we decided that the Plan does not have to pay for the cardiovascular genetic risk assessment testing (CPT code(s): 81404, 81405, and 81046) provided to the enrollee on December 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a resin-based composite (D2330 and D2391), and a partial maxillary denture (D5213) provided by a participating provider on August 3, 2021.  You asked the Plan to pay for a resin-based composite and a partial maxillary denture. You say that you would like the Plan to pay for all of this. The Plan denied your request. The Plan says the correct coinsurance has been applied to a resin-based composite. The Plan says that D5213 is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, D5213 are not among those covered under this benefit. A 505 coinsurance has been applied to D2330 and D2391. Therefore, we decided that the Plan does not have to pay for a partial maxillary denture (D5213) or waive the coinsurance for a resin-based composite (D2330 and D2391) provided by a participating provider on August 3, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) and a mount for a back cushion (K0108).  You asked the Plan to pre-approve an expandable controller with harness and electronic connection and a mount for a back cushion. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for coverage for the requested items have not been met.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that posterior pelvic cushions (E2613, E2614) are equipped with mounting hardware and that, if DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and 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 an expandable controller with harness and electronic connection and a mount for a back cushion. Our reviewer says that an expandable controller with harness and electronic connection are not considered medically reasonable and necessary in this case. Our physician reviewer found that provided records document that you are independent with feeding, thus indicating that you have adequate upper extremity strength and function to operate the wheelchair's power options with their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Additionally, the case record shows that the Plan has pre-approved item E2613 as an accessory for a Group 3 power wheelchair. Item E2613 is equipped with mounting hardware that serves the same purpose as a separate mount (K0108). A separate mount is not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311) and a mount for a back cushion (K0108).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).  You asked the Plan to pre-approve an expandable controller with harness and electronic connection. You say that the requested items are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage for the requested items have 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 an expandable controller with harness and electronic connection. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not require non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not require a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee has 3 power options of tilt, recline, and power elevating leg rests but the enrollee does not need to control the power options through a joystick. The enrollee's upper extremity strength and function support that the enrollee can control any power options through their own switches.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller with harness and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377) with harness (E2313) and electronic connection (E2311).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services (99291) provided on April 30, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99291 is "Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes."    We find that CPT code 99291 is not supported in the medical record. Specifically, the records provided do not show that 30-74 minutes of critical care services were provided on the date of service in question. 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 the critical care services (99291) provided on April 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 70544-26 billed for date of service September 21, 2021.  You asked the Plan to pay for procedure code 70544-26. You say that this patient had multiple exams on this date of service. The Plan denied your request. The Plan says this code is bundled and was not billed with an appropriate modifier to permit payment.  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, we have confirmed that code 70544-26 is a column II code to column I code 70551. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 70544-26 billed for date of service September 21, 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 you need an IRF admission covered. The Plan denied your request. The Plan says you do not meet the Medicare criteria for admission to an IRF.  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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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 you 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Milrinone Lactate.  You asked the Plan to pre-approve Milrinone Lactate. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the enrollee does not meet coverage criteria.  The Plan follows Medicare rules. Medicare rules state that administration of therapy using a drug such as milrinone may be covered under certain clinical circumstances.  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 Milrinone Lactate. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Milrinone Lactate. Our physician reviewer found the record indicates that the enrollee has acute on chronic systolic heart failure, New York Heart Association (NYHA) Class IIIA in the presence of a ventricular assist device. Therefore, this drug 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 Milrinone Lactate have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Milrinone Lactate.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the podiatry services provided on February 10, 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 podiatry services provided on February 10, 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 cardiac risk assessment genetic screening testing (CPT code(s): 81291, 81407, 81408, 81439) provided to the enrollee on July 1, 2020.  You asked the Plan to pay for the laboratory testing. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered by Medicare.  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 documentation does not indicate how the test results will assist in managing the enrollee's condition. Therefore, the denial of the cardiovascular screening/risk assessment panel is administratively upheld for not meeting Medicare coverage criteria. Therefore, we decided that the Plan does not have to pay for the cardiac risk assessment genetic screening testing (CPT code(s): 81291, 81407, 81408, 81439) provided to the enrollee on July 1, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the multiple laboratory testing provided on August 5, 2021.  You asked the Plan to pay for the lab testing. You say that this should be covered. The Plan denied your request. The Plan says this was billed with a diagnosis of Encounter for general adult medical examination without abnormal findings. As such, it is considered screening testing.  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 records provided do not document any signs or symptoms of disease for which this testing was ordered. This was billed with a screening diagnosis code. Therefore, we decided that the Plan does not have to pay for the multiple laboratory testing provided on August 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the discharge services (99239) provided on March 2, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  In this case, the CPT Code Manual definition of code 99239 is "Hospital discharge day management; more than 30 minutes".  We find that CPT code 99239 is not supported in the medical record. Specifically, the records do not show that more than 30 minutes of hospital discharge day management services were provided on the date of service in question. 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 the discharge services (99239) provided on March 2, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on October 25, 2021.  You asked the Plan to pay for the abdominal ultrasound. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare coding regulations.  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, we have confirmed that code 76700 is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the abdominal ultrasound (76700) provided on October 25, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the Tempus gene panel (81479) provided on March 22, 2021.  You asked the Plan to pay for the Tempus gene panel. You say that you would like reconsideration because this testing was ordered by the member's treating physician. The Plan denied your request. The Plan says that all laboratory tests must be ordered by the physician who is treating the member.  The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Tempus gene panel have been met. Specifically, the Plan has stated that they received a physician order from the member's in-network provider. The records also includes a physician order for the Tempus gene panel. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated. Therefore, we decided that the Plan has to pay for the Tempus gene panel (81479) provided on March 22, 2021.   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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.  You asked the Plan to pre-approve the continued SNF care. You say that you do not have anyone to take care of you. You also say that you can have assistance at home, but not for 24 hours, and if you fall in the middle of night, no one will be there to help you and you would be there until someone comes the next day for in home help. The Plan denied your request. The Plan says your request for approval of continued SNF care does not meet the requirements for approval.  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 continued SNF care. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on 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 the continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator (E0466).

You asked the Plan to pre-approve a portable ventilator. You say that the item is medically necessary. The Plan denied your request. The Plan says the requested device is being used in the bilevel PAP mode rather than being used as a home ventilator.

The Plan must follow Medicare rules. The rules say that claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as not reasonable and necessary.

We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on September 23, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on September 23, 2021.