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 IRF care is medically necessary for the enrollee's
condition. The Plan denied your request. The Plan says rules for IRF care have not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the patient was admitted for surgical management of subdural hematoma.
Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient 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. In conclusion, there is not a reasonable expectation that this patient 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 foldable power scooter.

You asked the Plan to pre-approve power scooter. You say that your power wheelchair no longer works for you and the needed repairs are bad. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because it is appropriate to repair your current power wheelchair instead of providing a new power mobility device.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 power scooter. Our reviewer says that you do not meet the Medicare criteria for the requested power scooter. Our physician reviewer found the documentation indicates that your current power wheelchair can be repaired. The documentation does not reveal that you can safely operate the requested foldable power scooter or that you require this to perform mobility-related activities of daily living in the home. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a foldable power scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the fluorodeoxyglucose (FDG) positron emission tomography (PET) scan provided on March 15, 2021, billed with diagnosis code K86.89.
You asked the Plan to pay for the FDG PET interpretation. You say that this was medically necessary and reported with the correct diagnosis. The Plan denied your request. The Plan says this is not an appropriate diagnosis for this service.
The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used.
We looked at the file and Medicare rules. Diagnosis code K86.89 is defined as Other specified diseases of pancreas. This is not among the Medicare-covered diagnosis codes for this imaging. Based on this information, we decided that Medicare rules for coverage of the FDG PET interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the fluorodeoxyglucose (FDG) positron emission tomography (PET) scan provided on March 15, 2021, billed with diagnosis code K86.89.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance supplies (A0382) provided to you on August 2, 2020.

You asked the Plan to pay for the supplies. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services. 

We looked at the file and Medicare rules. Per Medicare rules, the requested ambulance supplies are bundled into the ambulance payment and are not separately payable. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance supplies (A0382) provided to you on August 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telehealth visit provided on March 25, 2021 with a family practitioner.

You asked the Plan to waive the copayment for the telehealth visit. You say that these services have never had a copayment in the past. The Plan denied your request. The Plan says this copayment was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $10 copayment for telehealth visits with a primary care provider. 

The enrollee has been asked to pay a $10 copayment for the telehealth visit. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the telehealth visit provided on March 25, 2021 with a family practitioner.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
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 records show that you have
osteoporosis and are unable to take oral bisphosphonate medication due to esophageal disease. You have not
tried and failed the Plan's required drug, zoledronic acid. The records do not show that the required drug cannot
be used or would be less effective; therefore, Prolia is 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 Prolia.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the interpretation of the positron emission tomography (PET) scan provided on March 30, 2021, billed with diagnosis code C50.911.

You asked the Plan to pay for the PET scan interpretation. You say that this was reported with the correct diagnosis based on the enrollee's condition. This imaging was medically necessary and should be paid. The Plan denied your request. The Plan says this was not billed with an appropriate diagnosis code.

The Plan must follow Medicare rules. Medicare rules say that the number of PET scans that are allowed are based on the exact diagnosis for which they are provided. As such, Medicare has a list of appropriate diagnosis codes that may be used.

We looked at the file and Medicare rules. C50.911 is defined as Malignant neoplasm of unspecified site of right female breast. However, this is not present on the Medicare list of appropriate diagnosis codes for this service. The appropriate codes for this service require that the site of the cancer in the breast be specified. Based on this information, we decided that Medicare rules for coverage of the PET scan interpretation have not been met. Therefore, we decided that the Plan does not have to pay for the interpretation of the positron emission tomography (PET) scan provided on March 30, 2021, billed with diagnosis code C50.911.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for manual therapy (97140) and physical therapy (97161) provided on April 8, 2021, to April 21, 2021.

You asked the Plan to waive the copayment for manual and physical therapy. You say that you did not visit the provider at the hospital until April 21, 2021. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $20 copayment per provider, per date of service, for outpatient rehabilitation services provided in various outpatient settings, such as hospital outpatient departments.

You have been asked to pay a $20 copayment per provider, per date of service, for manual and physical therapy. The records provided for review confirm that you had manual and physical therapy visits in an outpatient setting. The EOC confirms $20 is the correct copayment per visit. Manual and physical therapy fall within the outpatient rehabilitation services benefit category. 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 copayment for manual therapy (97140) and physical therapy (97161) provided on April 8, 2021, to April 21, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital visits: initial and subsequent (99221)
provided May 5, 2021.
You asked the Plan to pay for the inpatient services. You say that please review claim for reprocessing the
bundled payment denial when the two providers on this date of service are different specialty. The Plan denied
your request. The Plan says separately billed services, tests have been bundled as they are considered
components of the same procedure. Initial hospital care service was processed under another claim, rendered by
another provider within the same group and of the same specialty.
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 the
inpatient services has a bundled relationship with code 99223 and cannot be paid as billed. This code cannot be
paid as a separate line item. 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 inpatient hospital visits: initial and subsequent
(99221) provided May 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the percutaneous transluminal mechanical thrombectomy
(36905), additional sedation time (99153), and imaging guidance (76937) provided on April 8, 2021.
You asked the Plan to pay for the services as billed. You say that this was billed correctly and should be paid.
The Plan denied your request. The Plan says this was not billed with an appropriate POS code.
The Plan must follow Medicare rules. Medicare rules say that the POS code for services provided to hospital
inpatients should be POS 21, regardless of where the face to face services occurs.
In this case, the Plan has provided evidence that the enrollee was an inpatient on this date of service. As such,
the reported POS of 22 is not supported. Therefore, we decided that the Plan does not have to pay for the
percutaneous transluminal mechanical thrombectomy (36905), additional sedation time (99153), and imaging
guidance (76937) provided on April 8, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that your needs can be met safely at an alternate level of 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental crowns, prefabricated post and core, endodontic therapy, periodontal scaling and root planing, gingival irrigation, dentures, extractions, and the localized delivery of antimicrobial agent.

You asked the Plan to pre-approve the comprehensive dental services. You say that this is a life and death situation. You say that you have bacteria growing in your mouth. The Plan denied your request. The Plan says the comprehensive dental benefit is exhausted for this quarter.

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 benefit for comprehensive dental services is limited to $375 per quarter. The records show that this quarterly $375 comprehensive dental benefit was exhausted with the pre-approval of a crown on tooth #6. Therefore, we decided that the Plan does not have to pre-approve dental crowns, prefabricated post and core, endodontic therapy, periodontal scaling and root planing, gingival irrigation, dentures, extractions, and the localized delivery of antimicrobial agent.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that you can appropriately receive therapy at a lower level of 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for emergency department (ED) visit (99285) provided on
January 20, 2021.
You asked the Plan to pay for the ED visit. You say that the ED visit was medically necessary. The Plan denied your request. The Plan says that the physician medical group was contacted for prior authorization for out of network services and it was refused.
The Plan must follow Medicare rules. The rules say that an emergency exists based on a prudent layperson standard, not a retrospective medical review. For symptoms to be considered emergent in nature, they must be such that a prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical attention would result in serious jeopardy to their health. We decided that this case does meet prudent layperson criteria for emergency care. A prudent layperson with an average knowledge of medicine would reasonably expect the absence of immediate medical care to seriously jeopardize their health in this case. Therefore, we decided that the Plan has to pay for emergency department (ED) visit (99285) provided on January 20, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203), arthrocentesis, aspiration and/or
injection, of a major joint or bursa (20610), unclassified drug injection (J3490), and the triamcinolone
acetonide injection (J3301) rendered by the out-of-network (OON) provider on January 29, 2020.
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 visit (99203), arthrocentesis, aspiration and/or injection, of a major
joint or bursa (20610), unclassified drug injection (J3490), and the triamcinolone acetonide injection (J3301)
rendered by the out-of-network (OON) provider on January 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit services provided by a chiropractor on April 6, 2021.
You asked the Plan to pay for the office visit services. You say that you were referred to this chiropractor by your doctor. This was not to treat your lumbar pain but for a torn gluteal muscle. The Plan denied your request. The Plan says these services are not covered by Medicare or your Plan.
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 service at issue is not manual manipulation of the spine. This was an office visit charge which is not covered even if manual manipulation of the spine is also provided. Therefore, we decided that the Plan does not have to pay for the office visit services provided by a chiropractor on April 6, 2021
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 15 additional physical therapy visits.
You asked the Plan to provide 15 additional application of a modality (97033), therapeutic procedure (97110), and electric current therapy (97033). You say that the enrollee needs additional therapy to assist with falling and improve ambulation. The Plan denied your request. The Plan says clinical notes do not show that ongoing physical therapy will result in the practical improvement in the enrollee's level of function within a predictable period of time.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 provide 15 additional application of a modality (97033), therapeutic procedure (97110), and electric current therapy (97033). Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The patient has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further 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 15 additional application of a modality (97033), therapeutic procedure (97110), and electric current therapy (97033) have not been met. Therefore, we decided that the Plan does not have to provide 15 additional physical therapy visits.