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

We decided that the Plan does not have to pre-approve a power wheelchair (K0821).
You asked the Plan to pre-approve the power wheelchair. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the power wheelchair. Our reviewer says that the power wheelchair is not medically necessary. Our physician reviewer found the documentation states that the patient's deficit cannot be helped by a walker, cane, or manual wheelchair due to shortness of breath with using her arms for repetitive activity. The patient may have the cognitive ability to use a Power wheelchair but the documentation is not clear that her home has the capacity or space for her to safely maneuver the requested device around.
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 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair (K0821).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous laminectomy.
You asked the Plan to pre-approve percutaneous laminectomy. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is considered medically appropriate when member is enrolled in clinical study, but member is not in a clinical study.
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 percutaneous laminectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the percutaneous laminectomy surgery remains experimental. More research is needed to show safety and efficacy of the procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous laminectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous laminectomy.
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 need continued rehabilitation in order to recover fully and do not believe you can get that at a skilled nursing facility. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of 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. 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 were admitted for non-operative management of low back pain attributed to lumbar disc disease. Your medical conditions are stable. There are 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. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: 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 admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 the complexity of the nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The admission was for COVID 19, pneumonia and respiratory failure. Medical conditions are stable. There are no complex nursing or rehabilitation needs.
There is not a need for treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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 of an ability 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 23 additional physical therapy visits.
You asked the Plan to pre-approve physical therapy. You say that you feel this therapy is crucial to healing. The Plan denied your request. The Plan says the denial of authorization for additional physical therapy is correct, because you are stable to continue rehabilitation with a home exercise program and follow-up with your physician.
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 pre-approve physical therapy. 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 requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was already approved by the Plan. You have had extensive prior therapy for your condition and the records do not demonstrate significant deficits that require the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapy or under the supervision of a therapist. You should be able to transition to an independent home exercise program. The requested services are not part of a maintenance program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 23 additional physical therapy visits.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an assisted living placement.
You asked the Plan to pre-approve the assisted living placement. You say that you would benefit from being in an assisted living facility. You say that you have balance issues and no one around in case you fall and cannot get up. You say that you feel you may have Parkinsonism setting in. You say that you fell you would benefit from increased socialization and this would provide you with 3 meals per day. The Plan denied your request. The Plan says there are other services that can be put into place to keep you safe in your apartment.
The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.
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 assisted living placement. Our reviewer says that the requested assisted living placement is not medically necessary. Our physician reviewer found the requested service is not medically necessary as the interdisciplinary team (IDT) states that there are additional services that can be put in place to assist you with socialization and oversight to maintain your overall health status. The reviewer found that you do not require the requested assisted living placement which would exceed your current needs at this time. Therefore, the reviewer found that the requested placement is not medically 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 assisted living placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an assisted living placement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for the additional routine transportation trips. The Plan denied your request. The Plan says you have used 88 of the 96 trips and you have 8 remaining trips for 2021.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 96 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that at the time of your appeal you had 8 remaining trips for 2021. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on January 5, 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 services are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 96136 is 1. You billed 2 units of this code, exceeding the MUE. 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 testing services rendered on January 5, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is ready for discharge from
the hospital and would benefit from LTACH admission. The Plan denied your request. The Plan says the denial
of authorization for LTACH service is correct.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee continues to receive acute critical care services that have not been denied
by the Plan. The records provided do not indicate that the enrollee requires acute care services that she is not
currently receiving that would be available at the LTACH.
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 LTACH services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied
your request. The Plan says this is considered investigational.
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 procedure. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found this procedure remains experimental for the treatment of low back pain. More research is
needed to show safety and efficacy of the procedure.
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 procedure have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital procedures provided by
a participating hospital on October 16, 2020.
You asked the Plan to waive the copayment for outpatient hospital procedures. You say that you believe your
copayment should be $10. The Plan denied your request. The Plan says the correct copayment has been
applied.
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 $225
copayment for outpatient hospital services/outpatient surgery or procedure.
You have been asked to pay a $225 copayment for outpatient hospital procedures. The correct copayment has
been applied to the outpatient procedure that was provided. Outpatient hospital procedures falls within the
outpatient hospital services/outpatient surgery or procedure 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 outpatient hospital procedures provided by a participating hospital on October 16,
2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care provided on October 13 to October 26, 2020.
You asked the Plan to waive the copayment for inpatient mental health care. You say that you cannot afford to pay the balance. The Plan denied your request. The Plan says the correct copayment was applied.
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 $350 copayment for each day of days 1-5 of each Medicare-covered hospital stay. You have been asked to pay $1,750, or a $350 copayment for each day for days 1-5, for inpatient mental health care. 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 inpatient mental health care provided on October 13 to October 26, 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 you are bed bound, live alone, and will deplete if you cannot regain your strength because you are incapable of caring for yourself. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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 have a past medical history of diabetes, COPD, chronic respiratory failure and are living at home since discharge on May 12, 2021 from an acute care stay for chest pain. You have weakness and difficulty with ambulation and self-care. Your medical conditions are stable. There are 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. You do 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 you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a spinal distraction device.
You asked the Plan to pre-approve the insertion of a spinal distraction device. You say that the enrollee has suffered back pain that has greatly impacted his life. You say that this conservative procedure is a safe alternative to a spinal fusion. The Plan denied your request. The Plan says there are currently no clinical indications for this technology. The Plan says that this service is not covered under Medicare and is not considered to be reasonable and 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 the insertion of a spinal distraction device. Our reviewer says that the insertion of a spinal distraction device is not considered medically reasonable and necessary in this case. Our physician reviewer found spinal distraction devices remain experimental. More research is needed to show safety and efficacy of the devices. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the insertion of a spinal distraction device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a spinal distraction device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services (CPT 10021) provided to the enrollee on October 12, 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 the records support one unit for this date of service.
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 10021 is "Fine Needle Aspiration (FNA) Biopsy." 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 services at issue in this case were not supported by the medical records. Our coding reviewer found CPT 10021 was billed incorrectly, there is a more appropriate modifier to use when the same procedure is performed at separate anatomic sites or at separate patient encounters on same date to indicate they are different procedures on that date of service.
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 imaging services (CPT 10021) provided to the enrollee on October 12, 2020.