Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says an IRF admission 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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a stroke. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a supply allowance for a therapeutic CGM.
You asked the Plan to provide a supply allowance for therapeutic continuous glucose monitor (K0553). You say that the enrollee needs a CGM. The Plan denied your request. The Plan says the enrollee does not meet the insulin criteria.
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 assesses 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 three or more daily administrations. Based on this information, we decided that Medicare rules for coverage of supply allowance for therapeutic continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to provide a supply allowance for a therapeutic CGM.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telehealth services billed with Current Procedural Terminology (CPT) code G0426 provided on March 15, 2021.

You asked the Plan to pay for CPT G0426. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were billed with the incorrect 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, the CPT Code Manual definition of code G0426 is [a telehealth consultation, emergency department or inpatient, typically lasting 15 minutes in communication with the patient. 

We find that CPT code G0426 is not supported in the medical record. Specifically, use of this CPT code requires the patient to be either in the emergency room or an inpatient in a hospital. Records show that the patient was in a nursing facility when these services were provided. That is why this telehealth code is not billed appropriately. Based on this information, we decided that Medicare rules for coverage of CPT G0426 have not been met. Therefore, we decided that the Plan does not have to pay for telehealth services billed with Current Procedural Terminology (CPT) code G0426 provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from
October 1, 2020 to October 20, 2020.

You asked the Plan to pay for home health 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 as billed.

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 RAP
claim was submitted with the incorrect date of service. Therefore, we decided that the Plan does not have to
pay for the home health services provided to the enrollee from October 1, 2020 to October 20, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone replacement graft, the surgical placement of an implant body, an abutment supported cast metal crown, and a prefabricated abutment.

You asked the Plan to pre-approve a bone replacement graft, the surgical placement of an implant body, an abutment supported cast metal crown, and a prefabricated abutment. You say that the services being requested are medically necessary. The Plan denied your request. The Plan says the requested services are not covered under the enrollee's benefit package.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a bone replacement graft, the surgical placement of an implant body, an abutment supported cast metal crown, and a prefabricated abutment.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services billed with current procedural terminology (CPT) code 97530-GO-CO-KX on May 7, 2020.

You asked the Plan to pay for CPT code 97530-GO-CO-KX. You say that these services were medically necessary. The Plan denied your request. The Plan says the code billed is not supported in the medical record.

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 97530-GO-CO-KX is therapeutic activities to improve functional performance, per 15-minute increment. 

We find that CPT code 97530-GO-CO-KX is not supported in the medical record. Specifically, although the medical record denotes the 'time in' and 'time out' of the occupational therapy assistant who performed these services, there is no notation in the medical records as to the length of time that each therapeutic exercise lasted. The code billed is a timed code and this information is required. Furthermore, the medical records indicate that this service was performed in a home health setting. Therapeutic exercises performed by an occupational therapy assistant in a home health setting should be coded as G0158 instead of the code billed. Based on this information, we decided that Medicare rules for coverage of CPT code 97530-GO-CO-KX have not been met. Therefore, we decided that the Plan does not have to pay for therapy services billed with current procedural terminology (CPT) code 97530-GO-CO-KX on May 7, 2020.
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 24, 2021 to February 27, 2021.
You asked the Plan to pay for home health 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 as billed.
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 rules say the Type of Bill is a required data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 24, 2021 to February 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on December 4, 2020.
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 medical records do not support the billing of code 25447.
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 25447 is interposition arthroplasty, intercarpal or carpometacarpal joints. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the medical records do not support the billing of code 25447.
Our reviewer found the record indicates that the enrollee underwent an operative procedure on December 4, 2020. The operative report provided does not indicate that arthroplasty was performed as defined in the coding rules. The elements of the coverage criteria are not satisfied. We looked at this coder'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 pay for the surgical services rendered on December 4, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 5, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device.

You asked the Plan to pre-approve a MyoPro 2 Motion G orthotic device. You say that traditional therapies have been trialed and failed. You say that the requested device would immediately restore the enrollee's left arm function and range of motion. You say that there is a high level of supporting evidence that goes above and beyond what is normally required for coverage of other high-tech durable medical equipment. You say that the requested device is specifically intended to meet the functional needs of the enrollee by restoring his ability to independently reach, grasp, release, hold, and coordinate movement of the impaired arm for engagement in performing activities of daily living. The Plan denied your request. The Plan says medical studies have not proven that the device in dispute 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 a MyoPro 2 Motion G orthotic device. Our reviewer says that a MyoPro 2 Motion G orthotic device is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy, including constraint induced movement therapy, conventional muscle strengthening, and Botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

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 MyoPro 2 Motion G orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87502, 87581, and 87634) provided on June 2, 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 tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87502, 87581, and 87634) provided on June 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided from March 2, 2021, through March 4, 2021.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
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 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 physical therapy services provided from March 2, 2021, through March 4, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay for the outpatient surgery services provided on July 21, 2020.

You asked the Plan to pay for the outpatient surgery services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says that the claim was not filed
timely.

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. Medicare regulations define the timely filing period for Medicare claims. In
general, such claims must be filed to the appropriate Medicare claims processing contractor no later than 12
months, or 1 calendar year, after the date of services were furnished. In this case, the date the services were
furnished was July 21, 2020. The claim was submitted for payment on January 20, 2021, well within the timely
filing period for submitting claims for payment. Therefore, we decided that the Plan has to pay for the
outpatient surgery services provided on July 21, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: 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 it is felt that the enrollee would benefit from IRF care. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to an acute hospital on 8/8/21 with endocarditis. She required surgery including removal of an implanted cardioverter-defibrillator. Postoperatively, she developed slow heart rate which required a pacemaker. She was successfully extubated with continuing atrial fibrillation.

She has severe debility with anemia as of 8/23/2021.

Documentation does not support the need for therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with current level of function requiring rest breaks. Functionally, at the current level as above, she cannot tolerate IRF level of therapies. While she would benefit from PT, and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S2900) provided on September 7, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code S2900 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 services (S2900) provided on September 7, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Vitamin D testing rendered on February 8, 2021.
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 testing is 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, a Vitamin D assay, 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 Vitamin D testing rendered on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on December 22, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the outpatient services are not payable.
The Plan must follow Medicare rules. Medicare rules say that there is no payment under the Outpatient Prospective Payment System (OPPS) for services that CMS designates to be "inpatient-only" services. We looked at the file and Medicare rules. In this case, the outpatient claim cannot be paid due to the inpatient only procedure being provided on the same date of service. 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 services provided on December 22, 2020.