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 for the enrollee.
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 the enrollee's 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 the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for a lumbar laminectomy and fusion. The enrollee's 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 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 patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on July 8, 2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not 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, the CPT Code Manual definition of code 97530 is therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes. We find that CPT code 97530 is not supported in the medical record. Specifically, the medical records indicate that these services were performed in the home health or hospice setting. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on July 8, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forphysical therapy provided on October 27, 2020.You asked the Plan to pay forthe physical therapy. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physical therapy. 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 forphysical therapy provided on October 27, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home ventilator.
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says there are no notes showing a doctor visit in the last six months.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found there is a physician note dated February 2, 2021. The oxygen saturation was noted to be greater than 92%. You were diagnosed with acute bronchitis, treated, and given a six-month follow-up. The note does not indicate the intention to order a home ventilator. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nexlizet for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Nexlizet for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from February 20, 2020, to February 21, 2020.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary in this case. Our physician reviewer found that by 7:51 a.m. on February 20, 2020, the enrollee was deemed stable for transfer to a Plan facility by the treating physician. The review indicates that after 7:51 a.m. on February 20, 2020, the enrollee was hemodynamically and neurologically stable and appropriate for ambulance transport with monitoring to a plan facility for continued observation/inpatient level of care services. The post-stabilization care services provided after this time at the non-Plan facility were not medically necessary or reasonable. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from February 20, 2020, to February 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that your health is in jeopardy.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.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 your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 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 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 27, 2021.
You asked the Plan to pay for the panoramic x-ray. You say that this x-ray was requested by a medical center in preparation for an upcoming medical surgery. You feel that you needed this x-ray for the surgery, and it is only being considered dental because you received it from your dental provider on the same day as your cleaning. The Plan denied your request. The Plan says panoramic x-rays are not covered by Medicare or by the Plan's supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.
A panoramic x-ray is considered a dental service, which is not typically covered by Medicare. Medicare can, in certain instances, cover otherwise non-covered procedures or services performed by a dentist if they are an integral part of a covered procedure or service performed by the dentist. Examples might include extractions that are required for radiation treatment of a neoplastic disease, wiring of teeth in connection with reduction of a jaw fracture, and reconstruction of a ridge performed as a result of and at the same time as the surgical removal of a tumor.
You say this panoramic x-ray was performed in relation to an upcoming surgery which will take place at a different medical center. The upcoming procedure will not be performed by the same dentist who took the x-ray, and it is unclear if this dental x-ray is incident to and an integral part of the upcoming medical procedure.
This exception does not apply. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on January 27, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency department services (99285) provided on August 5, 2020.
You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the evaluation and management level as reported on the claim.
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 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the emergency department services. Our reviewer says that CPT code 99285 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not support medical decision making of high complexity in CPT 99285, therefore, CPT 99285 would not be the appropriate code to report.
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 emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for emergency department services (99285) provided on August 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation (A0888) you received on September 23, 2020.
You asked the Plan to pay for the ambulance services. You say that your doctor said that you should go to this facility. The Plan denied your request. The Plan says transportation is only covered to the nearest facility.
Medicare pays for ambulance services only when transportation is provided to the nearest facility equipped to provide necessary care. The Plan follows the same rules. We looked at the file and Medicare rules. The records show that you were not transported to the nearest facility equipped to provide the necessary care for your condition. You were transported to a facility that was further away than the nearest facility. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transportation (A0888) you received on September 23, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided on December 19, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the services were not approved.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.

The enrollee was referred for the services by a contract provider. The file does not show that the plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the plan. Therefore, we decided that the Plan has to pay for the lab services provided on December 19, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion services (99601 and 99602) provided on November 13, 2020.

You asked the Plan to pay for the home infusion services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT codes 99601 and 99602 have status indicators of I meaning they are not valid for Medicare purposes.

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 CPT codes 99601 and 99602 are not supported in the record. Specifically, per the Physician Fee Schedule, CPT codes 99601 and 99602 have status indicators of I. This means that these codes are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion services (99601 and 99602) provided on November 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for IRF admission and services.
You asked the Plan to pay for IRF care. You say that you felt it was medically necessary for the enrollee as
there was a fear of COVID-19 to leave the hospital in her condition. You say that based on the doctor's
recommendation, the enrollee met all the levels of needed to stay in the hospital for the rehabilitation program.
You say that, at the time, all of the rehabilitation facilities in the area were reporting COVID-19 and the
enrollee felt safe staying where she was. The Plan denied your request. The Plan says the enrollee did not need
three hours a day of therapy and the enrollee's medical condition was stable and did not need a physician to
monitor three times a week.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of the enrollee's nursing, medical and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for surgical repair of a hip fracture after a fall. The 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 pay for IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, two periodontal maintenance services, extraction, and first intraoral periapical x-ray provided from August 3, 2020, to November 4, 2020.

You asked the Plan to pay for the periodic oral evaluation, bitewing x-rays, two periodontal maintenance services, extraction, and first intraoral periapical x-ray. You say that you were not aware that you needed to choose a provider in the Plan's network. The Plan denied your request. The Plan says the treating provider opted out of Medicare effective February 25, 2015, to February 25, 2021. The Plan also says that charges incurred by Medicare opt out providers will not be reimbursed.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, bitewing x-rays, two periodontal maintenance services, extraction, and first intraoral periapical x-ray provided from August 3, 2020, to November 4, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from October 11, 2020, through November 10, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for inpatient SNF 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that the enrollee is a 77-year-old male with CVA, asthma, BPH. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He had uncomplicated wound care to his right buttock MASD. His lungs were clear. He used oxygen via nasal cannula. Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee was at a dependent to maximal assist level with functional mobility. The beneficiary required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
The enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from October 11, 2020, through November 10, 2020.