Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty frame (K0108) for a manual wheelchair.
You asked the Plan to pre-approve a heavy duty frame. You say that the requested item is a medical necessity for you. The Plan denied your request. The Plan says rules for a heavy duty frame have not been met.
The Plan must follow Medicare rules. Medicare rules say that bBilling for construction material is considered incorrect coding. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a heavy duty frame have not been met. Specifically, the request is for construction materials or a heavy duty package reflecting the type of material used to construct the manual wheelchair base. Therefore, we decided that the Plan does not have to pre-approve a heavy duty frame (K0108) for a manual wheelchair
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a radiofrequency ablation of the facet joint of the right lumbar spine (64635, 64636).
You asked the Plan to pre-approve a radiofrequency ablation of the right lumbar spine. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for radiofrequency ablation have not been met.
The Plan must follow Medicare rules. Medicare rules say that, for each covered spinal region, no more than 2 radiofrequency sessions will be reimbursed per rolling 12 months. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a radiofrequency ablation of the right lumbar spine have not been met. Specifically, the case record indicates that the enrollee has received 2 prior radiofrequency ablations of the right lumbar spine fewer than 12
months ago (in January and June of 2021). Therefore, we decided that the Plan does not have to pre-approve a
radiofrequency ablation of the facet joint of the right lumbar spine (64635, 64636).
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 denial of LTACH services will seriously jeopardize he enrollee's life, health, and ability to regain function. The Plan denied your request. The Plan says the enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital.
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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 74019 provided on April 22, 2021. 
 
You asked the Plan to pay for the x-ray services. You say that you feel this claim should be paid. The Plan 
denied your request. The Plan says the services billed are not separately payable.

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 74019 
for the x-ray services has a bundled relationship with code 74022 and cannot be paid as billed. Both codes were 
provided on the same date of service by a physician of the same specialty in the same billing group. 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 x-ray services coded 74019 provided on 
April 22, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested level of care 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that no required skilled nursing services are identified. The enrollee would likely benefit from skilled therapy services; however, the documentation does not support that it is medically reasonable and necessary to provide skilled services on a daily basis in a skilled nursing facility on an inpatient basis. 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 SNF care.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a HHA 12 hours per day, beyond the 3 months that the 
Plan approved. 
 
You asked the Plan to pre-approve the HHA. You say that HHA services make an enormous difference to your 
overall quality of my life. You also say that without all the services you need, you are afraid you will need to 
go into a hospital or nursing facility setting instead of living in the community. The Plan denied your request. 
The Plan says based upon the documentation, the care team is working with you to establish the necessary 
community resources needed. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 pre-approve the HHA. Our reviewer says that the 
additional HHA services are not medically reasonable and necessary. Our physician reviewer found you are in 
need of skilled nursing services (PEG, vent monitoring, skin evaluations). You are not in need of skilled
therapy services (bedbound status). Our reviewer found that intermittent HHA services are medically necessary 
and reasonable to assist in your (bathing, dressing), and are coverable in conjunction with your skilled nursing 
services.  Our physician reviewer also found that additional aide services, so as to provide 24-hour care 7 days 
per week of supervision, is not intermittent and is not coverable. 
 
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 HHA have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a HHA 12 hours per day, beyond the 3 months that the Plan approved.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0427, A0425) received January 19, 2021.
You asked the Plan to waive the copayment for the ambulance transportation. You say that you should not be responsible for this charge. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $300 copayment for Ambulance Services. You have been asked to pay a $300 copayment for the ambulance transportation. The ambulance transportation falls within the Ambulance 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 the ambulance transportation (A0427, A0425) received January 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will receive the appropriate level of care 
in the acute rehabilitation setting. The Plan denied your request. The Plan says there is no documentation of the 
medical necessity of at least two disciplines requiring active and ongoing therapeutic intervention. 
 
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 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. The patient does require physical and occupational therapy but there is no 
documented need for an intensive rehabilitation program. Medically necessary services can be provided in a 
different level of care. 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 an expandable controller (E2377, E2311).
You asked the Plan to pre-approve an expandable controller. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee can control the power options through their own switches.
The Plan follows Medicare rules. Medicare rules say that an expandable controller is covered when it is medically necessary for a function listed in the LCD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve an expandable controller. Our reviewer says that the requested expandable controller is not medically necessary. Our physician reviewer found the documentation does not support a medical need to control power options through a joystick. The enrollee is independent with activities of daily living. The documentation does not support that the enrollee's upper extremity strength and function are inadequate to control the power options using switches which are included with these power options. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2311).
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 enrollee exceeds the CMS criteria for a LTACH admission. The Plan denied your request. The Plan says the enrollee can receive the same services at the current level of care.
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 patient appears to be improving but requires additional short-term acute care services to further stabilize her anemia and to further wean which can be safely completed at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary due to no advantage to transfer at this time. Transfer to a lower level of care may be considered when treatment has completed and the patient is more stable.
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 waive the copayment for an inpatient hospital stay from December 
14, 2020, through December 18, 2020. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you disagree with the 
charges. The Plan denied your request. The Plan says the copayment was applied 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). Your contract with the Plan clearly says that you must pay a $325 
copayment per day for days 1-6 for inpatient hospital care.  
 
You have been asked to pay a $325 copayment per day for days 1-6 of an inpatient hospital stay. The services 
at issue fall within the inpatient hospital care 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 an inpatient hospital stay from December 14, 2020, through December 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve electronic brachytherapy for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is insufficient long-term efficacy and safety data to support electronic surface brachytherapy.
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 requested services are not considered medically reasonable and necessary in this case. From the appeal documentation it appears that a scalp lesion will be treated with radiation. The consultation note is unclear on this though (as it lists 5 benign lesions without describing a scalp skin cancer). There is a lack of demonstration of need for electronic brachytherapy versus traditional external beam radiation. Statements from NCCN guidelines and medical societies question its use. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve electronic brachytherapy for the enrollee
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97110) provided on June 24, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 
not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97110 is "Therapeutic procedure, 1 or more areas, each 
15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility".  
 
We asked our coding 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 use 
of code 97110 is not supported by the records provided. Our coding reviewer found that a Physical Therapy
Assistant (PTA) is not considered a qualified healthcare provider when reporting Current Procedural 
Terminology (CPT) codes. A Healthcare Common Procedure Coding System (HCPCS) code is a more 
appropriate for PTA services. 
 
We looked at this coder'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 the services (97110) provided on June 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department visit (99285) provided November 6, 2020.
You asked the Plan to pay for the emergency visit. You say that please review the attached supporting documentation and kindly reprocess for payment. The Plan denied your request. The Plan says 99285 is not supported by the submitted medical documentation.
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided. In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):
1. a comprehensive history; 2. a comprehensive examination; and 3. medical decision making of high complexity. In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function. 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 emergency visit. Our reviewer says CPT code 99285 is not supported in the medical record. Our reviewer found the emergency room visit does not supports a comprehensive history and exam, and medical decision making of moderate complexity with medical decision making of moderate complexity. CPT 99284 is a more appropriate code to report. 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 emergency visit have not been met. Therefore, we decided that the Plan does not have to pay for emergency department visit (99285) provided November 6, 2020.
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 this is medically necessary. The Plan denied your 
request. The Plan says rehab needs are not complex enough to require coordinated care between therapy 
disciplines. 
 
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 total hip replacement, ventricular tachycardia and anemia. 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 medical record supports a need for physical and/or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
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.