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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 cervical spine fractures C5 and C6 after a fall. He had cervical fusion with post-op complications including central cord syndrome and
delirium. Medical conditions 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, in an intensive rehabilitation therapy program. The enrollee 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. 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 pay for therapy services (97110) May 14, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 code 97110 is not supported in the medical record. Specifically, the record shows the services were provided in the home setting. There is a more appropriate CPT code to describe these services (G0151). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) May 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 25, 2021.
You asked the Plan to waive the copayment for the specialist office visit. You say that you saw the doctor and then went to your chemotherapy treatment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
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 $30 copayment for each Medicare-covered specialist visit (including surgery second opinion, telehealth services, and urgently needed services).
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" 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 specialist office visit provided on February 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for surgery.
You asked the Plan to pre-approve inpatient services. The Plan denied your request. The Plan says there is no documentation does not support the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. The file shows that inpatient hospital services were requested for the enrollee's approved shoulder surgery. 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 inpatient services. Our physician reviewer found that the enrollee presents with right shoulder pain for an elective right shoulder arthroplasty. She presents with normal vitals and was hemodynamically stable.
Past medical history includes hypertension, acid reflux, vitamin deficiency, IBS, leukopenia, anemia, and rheumatoid arthritis. Based on the provided documentation, this enrollee appears to have been stable and unlikely to require hospital services that would cross 2 midnights. There is no expectation of a complication or prolonged recovery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for surgery.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS HF device.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no definitive evidence that this device, compared to conventional medical management and clinical monitoring, has been established as a standard of care.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. 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 device. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent congestive heart failure, which appears very sensitive to volume-loading conditions, complexity of the medical regimen, and the failure to prevent acute congestive heart failure hospitalization, use of the the requested device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one 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 device have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS HF device.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on July 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services. The record shows CPT code 36415 was billed which means the provider had the opportunity to confirm insurance coverage and authorization. Therefore, we decided that the Plan does not have to pay for the laboratory work provided on July 1, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services coded 95885 and 95887, the nerve conduction studies coded 95907, and the digital analysis of electroencephalogram (EEG) coded 95957 provided on October 6, 2020.
You asked the Plan to pay for the needle electromyography services, the nerve conduction studies, and the digital analysis of electroencephalogram (EEG). 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 supported by the documentation.
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 95885, 95887, 95907, and 95957 are not supported in the medical record. Specifically, the technical report did not include documentation of a limited needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity
study; (listed separately in addition to code for primary procedure); therefore, code 95885 cannot be verified. The technical report did not include documentation of a needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (Listed separately in addition to code for primary procedure); therefore, code 95887 cannot be verified. The technical report did not include documentation of nerve conduction studies; for 1-2 studies; therefore, code 95907 cannot be verified. The technical report did not include documentation of a digital analysis of electroencephalogram (EEG) (for epileptic spike analysis); therefore, code 95957 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the needle electromyography services, the nerve conduction studies, and the digital analysis of electroencephalogram (EEG) have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography services coded 95885 and 95887, the nerve conduction studies coded 95907, and the digital analysis of electroencephalogram (EEG) coded 95957 provided on October 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99213, the chemotherapy
administration coded 96402, Leuprolide acetate coded J9217, measurement of post-voiding residual urine
and/or bladder capacity by ultrasound coded 51798, the complex uroflowmetry coded 51741, and the urinalysis
coded 81000 provided on December 15, 2020.
You asked the Plan to pay for the office visit, the chemotherapy administration, Leuprolide acetate,
measurement of post-voiding residual urine and/or bladder capacity by ultrasound, the complex uroflowmetry,
and the urinalysis. 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 supported by the documentation.
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 99213, 96402, J9217, 51798, 51741, and 81000 are not supported in the medical
record. Specifically, the documentation submitted did not include documentation of evaluation and
management of an established patient for the billed date of service; therefore, code 99213 cannot be verified.
The documentation submitted did not include documentation of chemotherapy administration, subcutaneous or
intramuscular; hormonal anti-neoplastic for the billed date of service; therefore, code 96402 cannot be verified.
The documentation submitted did not include documentation of Leuprolide acetate (for depot suspension), 7.5
mg was administered for the billed date of service; therefore, code J9217 cannot be verified. The
documentation submitted did not include documentation of measurement of post-voiding residual urine and/or
bladder capacity by ultrasound, non-imaging for the billed date of service; therefore, code 51798 cannot be
verified. The documentation submitted did not include documentation of complex uroflowmetry (e.g.,
calibrated electronic equipment) for the billed date of service; therefore, code 51741 cannot be verified. The
documentation submitted did not include documentation of urinalysis, by dip stick or tablet reagent for
bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any
number of these constituents; non-automated, with microscopy results for the billed date of service; therefore,
code 81000 cannot be verified.
Based on this information, we decided that Medicare rules for coverage of the office visit, the chemotherapy
administration, Leuprolide acetate, measurement of post-voiding residual urine and/or bladder capacity by
ultrasound, the complex uroflowmetry, and the urinalysis have not been met. Therefore, we decided that the
Plan does not have to pay for the office visit coded 99213, the chemotherapy administration coded 96402,
Leuprolide acetate coded J9217, measurement of post-voiding residual urine and/or bladder capacity by
ultrasound coded 51798, the complex uroflowmetry coded 51741, and the urinalysis coded 81000 provided on
December 15, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for wound repair services (14040) provided on March 31, 2020 by an out of network (OON) provider.
You asked the Plan to pay for wound repair services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says that prior authorization was not obtained for services rendered by an OON provider.
The rules say a plan must disclose to its enrollees in clear, accurate terms all information regarding prior authorization. The Plan contract does not say in clear and accurate terms that the enrollee must receive prior authorization for services rendered by an OON provider. We looked at the contract between the enrollee and the Plan. We did not see where the contract says enrollees must receive prior authorization for services rendered by an OON provider. The Plan contract clearly says that you never need approval in advance for OON services from OON providers. This means that the Plan did not follow Medicare rules for prior authorization. Therefore, we decided that the Plan has to pay for wound repair services (14040) provided on March 31, 2020 by an out of network (OON) provider.
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 injection provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the injection. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the injection provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar epidural steroid injection (CPT 62323).
You asked the Plan to pre-approve steroid injection. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve steroid injection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of the effectiveness and duration of pain relief from the second epidural steroid injection.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of steroid injection have not been met. Specifically, response to each epidural should be determined prior to determining the value of a repeat epidural. There is not documentation on the efficacy and duration of pain relief from your second injection. This means a repeat injection cannot be authorized. Therefore, we decided that the Plan does not have to pre-approve lumbar epidural steroid injection (CPT 62323).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve SNF admission. You say that the service is medically necessary. The Plan
denied your request. The Plan says the service 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 admission. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs, however, they are not needed on a daily
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 admission have not been met. Specifically, the enrollee does not require
daily skilled nursing or skilled therapy services. Medically necessary services can be obtained at a lower level
of care. This means admission into a SNF is not medically necessary. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for reevaluation and management services provided on July 29, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the reevaluation and management services. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the reevaluation and management services provided on July 29, 2020 by an out of network (OON) provider.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 was admitted with respiratory failure secondary to lung adenocarcinoma. The enrollee continues to receive acute critical care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the enrollee does not qualify for SNF
coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have
documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program
or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and,
as a practical matter, can be provided at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.