Persius/hicric huggingface dataset:
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found you were admitted to the hospital with chronic obstructive pulmonary disease (COPD), swelling of the limbs (peripheral edema), and venous stasis ulcers. You are now medically stable with no complex nursing or rehabilitation needs.
You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
You asked the Plan to pre-approve the facet joint injections. You say that the injections are medically necessary. The Plan denied your request. The Plan says the records do not support a second set of injections.
The Plan must follow Medicare rules. Medicare rules say that there must be a consistent positive response of at least 80% relief of primary (index) pain from the first set of injections. We looked at the file and Medicare rules. The file shows the initial set of injections only provided 20% pain relief. Based on this information, we decided that Medicare rules for coverage of the facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections (64493, 64494).
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says the clinical information provided does not show that the guidelines for coverage of IRF care have been met. The Plan says that the enrollee's needs can be safely met in a skilled nursing facility setting.
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 does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hypoglycemia, sepsis, acute cholecystitis, urinary tract infection, and metabolic encephalopathy. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 treat with insulin three or more times per day and does not require frequent adjustments on insulin dose base on blood
sugar testing. Based on this information, we decided that Medicare rules for coverage of these services have not
been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor
(CGM).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that inpatient skilled nursing facility care is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of inpatient skilled nursing facility care.

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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that you do not have documented skilled nursing or skilled therapy needs. You required minimal assistance during your August 11, 2021, session. Additional physical therapy was declined and no occupational therapy records were submitted. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.
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 disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with respiratory failure and Coronavirus pneumonia. She is now medically stable with no complex nursing or rehabilitation needs. She 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 the
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Laparoscopy, surgical, coded as 43281.  
 
You asked the Plan to provide coverage for surgery coded as 43281.  You say that the requested surgery is 
medically necessary. The Plan denied your request. The Plan says based on the medical records there is a more 
appropriate code that should be requested for prior authorization. Maximus overturned the Plans denial stating 
this surgery was shown to be medically necessary for the enrollee. The Plan requested a reopen and stated that 
the issue was not medical necessity but the fact that the incorrect code was being requested for this service. 
 
The Plan is correct in this case. Medicare require services to be requested appropriately. The Plan states the 
operative report states the service performed was for a "sliding hiatal hernia" and not a paraoesophageal hernia. 
The Plan agrees that code 43280 and not 43281, which was originally requested, was the more appropriate code 
for this surgery. As mentioned, prior, this was not a denial of service issue but an error in the code requested 
for coverage. Medicare criteria were not met for the service requested versus the actual service being provided. 
Therefore, we decided that the Plan does not have to provide coverage for surgical services requested under 
code 43281.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) at the L2-L3 levels.
You asked the Plan to pre-approve the RFA services. You say that the records provided support the need for the injection services which remain in dispute. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval.
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 RFA services. Our reviewer says that radiofrequency ablation at the L2-L3 levels is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. He has had RFA treatments at L3-L4, L4-L5 and L5-S1 with 80% pain relief. However, the request for repeat RFA has a different level, L2-L3 included. There is no documentation of prior diagnostic medial branch blocks (MBBs) or RFA at this level. There is no documentation supporting RFA at this level. 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) at the L2-L3 levels.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on August 12, 2021 with a right arm fracture are a fall and underwent surgical repair. You were walking 200 feet with a cane as of August 13, 2021. You were discharged home with recommendation for home health physical therapy. You have no skilled nursing needs. You have skilled therapy needs but do not require skilled nursing
on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits (G0299).
You asked the Plan to pre-approve the skilled nursing visits. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the skilled nursing visits. Our reviewer says that the requested home health services are not medically necessary. Our physician reviewer found the records do not show that the enrollee has any ongoing skilled nursing needs. 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 skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing visits (G0299).
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 these services are medically necessary. The Plan denied your request. The Plan says that your medical and therapy needs could be met in skilled nursing unit.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational
therapy services but based on the medical records provided you do not require an intensive inpatient rehabilitation therapy program. There is concern that you will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to your limited endurance and issues reported with your motivation to participate. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 29, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says if a laboratory assays two or more genes in a patient in parallel, then those two or more genes will be considered part of the same panel.
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 asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found 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. There was no specific clinical rationale for the requested laboratory studies. The laboratory services provided to the enrollee on December 29, 2020 were not 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits (99214) and the laboratory service (80305) rendered by the out-of-network (OON) provider from February 10, 2021, through April 12, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. 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 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 services 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 the office visits (99214) and the laboratory service (80305) rendered by the out-of-network (OON) provider from February 10, 2021, through April 12, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency care provided on November 26, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed incorrectly.

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 services in question were billed incorrectly. Specifically, the type of bill in this case does not match the provider type. The provider is certified by Medicare as a hospital facility; however, the claim was submitted with a type of bill for a clinic. 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 emergency care provided on November 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinous process interlaminar device.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested spinous interlaminar device remains experimental in cases of spinal surgery. More research is needed to show safety and efficacy of the devices. The services are therefore not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinous process interlaminar device.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on February 1, 2021.
You asked the Plan to pay for the laboratory 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 laboratory services provided on February 1, 2021.