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

We decided that the Plan does not have to pay for the laboratory services (CPT code 81226, 81225, 81227,
81230, 81355, 81241, 81240, 81291, 81479 and 81479-59-2) provided to the enrollee on July 19, 2021.
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 supported by the records.
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 enrollee had molecular pharmacogenetic testing on July 19, 2021. The denial remains upheld as non-
covered as Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel.
Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural
service, so one CPT code must be submitted for the panel. Based on this information, we decided that Medicare
rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not
have to pay for the laboratory services (CPT code 81226, 81225, 81227, 81230, 81355, 81241, 81240, 81291,
81479 and 81479-59-2) provided to the enrollee on July 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the magnetic resonance angiography
(MRA) of the head provided on September 25, 2021, billed with code 70544.
You asked the Plan to pay for the MRA interpretation as billed. You say that this should be paid. The Plan
denied your request. The Plan says an appropriate modifier was not used for this Column 2 code.
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
is a column II code to column I code 70553. 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 interpretation of the magnetic resonance angiography (MRA)
of the head provided on September 25, 2021, billed with code 70544.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for in-home physical therapy services you received on July 28, 2021, and August 6, 2021.

You asked the Plan to waive the copayments for the physical therapy services. You say that you were told that these sessions would be covered. The Plan denied your request. The Plan says these services were covered. However, you were charged the appropriate copayment for each date of service.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment per day for physical therapy services. 

You have been asked to pay a $35 copayment per day for the physical therapy services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for in-home physical therapy services you received on July 28, 2021, and August 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 27, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee out of medical
necessity. The Plan denied your request. The Plan says the rendering provider is a non-participating provider
and there was no referring provider or authorization for services. The services were also not urgent or
emergent.
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 an office visit provided on September 27, 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 nerve conduction studies (procedure code 95913) and
electromyography services (procedure code 95886) you received from a chiropractor on October 14, 2021.
You asked the Plan to pay for the nerve conduction studies and the electromyography services. You say that the
appointment with the chiropractor was set up by your primary care doctor and your orthopedic surgeon. You
were not aware that these services were not covered. The Plan denied your request. The Plan says these
services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not
manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for nerve
conduction studies (procedure code 95913) and electromyography services (procedure code 95886) you
received from a chiropractor on October 14, 2021.
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 the enrollee appears to be improving and requires only short-term additional acute care services including oxygen weaning that can be administered safely at the current facility. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. Transfer to a lower level of care may be considered when treatment has completed.

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: 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 the short-term acute care hospital can provide for all the enrollee's present inpatient care needs. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility.

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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve use of a hypoglossal nerve stimulator.

You asked the Plan to pre-approve hypoglossal nerve stimulator. You say that this is medically necessary for your life-threatening condition. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because you only had a home sleep study but have not had a sleep study performed in a freestanding or hospital sleep lab facility within the past 24 months.

The Plan must follow Medicare rules. The rules 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. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit medical records related to your request. We requested records but they were not submitted to us. The Plan says that they have denied your request because you have not had a sleep study performed in a freestanding or hospital sleep lab facility within the past 24 months. Without records, the Plan has not shown that this denial is correct or medically justified. Therefore, we decided that the Plan has to pre-approve use of a hypoglossal nerve stimulator.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actifuse allograft in spinal surgery setting.

You asked the Plan to pre-approve Actifuse allograft. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies have not proven that the use of this product during spinal surgery is better than standard allograft products.

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 Actifuse allograft. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found Actifuse allograft remains experimental in spine surgery. More research is needed before coverage can be approved.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actifuse allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve Actifuse allograft in spinal surgery setting.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve Eyela. You say that the requested drug is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says the requested drug is considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug
plan. The Plan also says the requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eylea.
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 does not meet criteria.

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 enrollee does not require the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Records do not indicate why the skilled nursing facility where the enrollee initially discharged to is not appropriate for the enrollee's care in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from February 15, 2022, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that additional inpatient psychiatric care is medically necessary for this enrollee. The Plan denied your request. The Plan says as of February 15, 2022, the enrollee no longer meets the criteria for psychiatric care at the acute inpatient level and can be treated in a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued psychiatric care at the inpatient level appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on January 12, 2022, with Schizophrenia Unspecified. Based upon a review of the provided records, it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, had no auditory or visual hallucinations and no aggressive behaviors. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question. It did not appear that active treatment was taking place beyond the dates in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of February 15, 2022, forward and could have been treated in a lesser restrictive 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 continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from February 15, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services coded as 98940, 72125 and 76377 provided on August 2, 2021 to October 14, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic services. You say that you spoke to the chiropractor and they stated they have used this code prior and it was accepted as manipulative treatment. You were not aware of needing an authorization and feel that you shouldn't be responsible for that. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 chiropractic services coded as 98940, 72125 and 76377 provided on August 2, 2021 to October 14, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker with seat attachment.

You asked the Plan to pre-approve a walker with seat attachment. You say that the requested walker with seat attachment is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested walker with seat attachment.

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 walker with seat attachment. Our reviewer says that the enrollee does not meet criteria for the requested walker with seat attachment. Our physician reviewer found the documentation does not reveal that the enrollee has a mobility limitation that significantly impairs her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home, places her at a risk of morbidity or mortality secondary to attempts to perform the MRADL, or prevents her from completing the MRADL in a reasonable time frame. The October 8, 2021, and October 26, 2021, progress note/office visit notes reveal normal gait on exam. The criteria for a walker with accessories have not been met per LCD L33791 and the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k) as the request exceeds the patient's medical need. 

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 walker with seat attachment have not been met. Therefore, we decided that the Plan does not have to pre-approve a walker with seat attachment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).

You asked the Plan to pre-approve the insertion of a Vertiflex device. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.

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 insertion of a Vertiflex device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show it is safe and effective. 

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 insertion of a Vertiflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Vertiflex device (22869).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 additional home health physical therapy visits (G0151).  You asked the Plan to pre-approve 2 additional home health visits. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for coverage for home health services have not been met.  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 2 additional home health visits. Our reviewer says that the requested services are not medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation that additional skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 additional home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 additional home health physical therapy visits (G0151).