Persius/hicric huggingface dataset:
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 LTACH care is medically necessary. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 to an acute care hospital for necrotizing fasciitis. At the time of the request, the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on December 16, 2020.
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 were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that chiropractic claims must be billed with the -AT modifier.
We looked at the file and Medicare rules. The file shows that the services were not billed with the required -AT modifier. 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 chiropractic services rendered on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on December 31, 2020.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the appropriate place of service (POS) code.
We looked at the file and Medicare rules. The file shows that the office visit was billed with POS code 12 for the home setting and this place of service is inappropriate for the services at issue. 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 office visit rendered on December 31, 2020.
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 this service is medically necessary. The Plan denied your request. The Plan says the enrollee does not medically require this service.
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 a left frontoparietal stroke related to COVID infection. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the podiatry services provided on January 18, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the podiatry services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 had network providers available who could have provided the items/services at issue in this appeal. 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 podiatry services provided on January 18, 2021 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a folding wheeled walker (E0143) provided on January 23, 2021, by a provider not enrolled in the Medicare program.
You asked the Plan to pay for a folding wheeled walker. You say that you were completely unaware that you should have called the Plan before you purchased a folding wheeled walker. The Plan denied your request. The Plan says rules for payment have not been met because the provider is not enrolled in the Medicare program.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for a folding wheeled walker (E0143) provided on January 23, 2021, by a provider not enrolled in the Medicare program.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically reasonable and necessary. Based on the documentation provided, it is my opinion that the health plan's denial should be overturned. The enrollee does require the intensity of services provided at an IRF. Specifically, the enrollee is shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. As a practical matter, the enrollee's care needs are unlikely to be met at a lower level of care (i.e. SNF). The Plan denied your request. The Plan says that the enrollee does not qualify for an IRF stay as she does not need to see a doctor regularly.
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 found to be medically reasonable and necessary for this enrollee. Our physician reviewer found the enrollee is a 69-year-old female who was admitted to an acute care hospital after being struck by her bike. Based on the medical records provided, the enrollee does require the intensity of services provided at an IRF. Specifically, the enrollee is shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. As a practical matter, the enrollee's care needs are unlikely to be met 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 IRF care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical procedure you had at an ambulatory surgical center on January 12, 2021.
You asked the Plan to waive the copayment for the outpatient surgery. You say that you received a bill for these services and were advised that the hospital had prior authorization to perform this surgery. The Plan denied your request. The Plan says you are not responsible for the non-covered services on the bill. The Plan says that you are only responsible for the copayment assessed for the surgery itself.
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 $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for the outpatient surgery. You are not being charged for the
services for which the facility failed to get prior authorization beyond this copayment. 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 outpatient surgical procedure you had at an ambulatory surgical center on January 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monthly rental charge for a neuromuscular electrical stimulation (NMES) device billed with a September 5, 2020 date of service (DOS).
You asked the Plan to pay for the NMES rental charge. You say that the documentation supports the need for this item. The Plan denied your request. The Plan says no proof of delivery for this NMES device was submitted despite requests.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain a valid proof of delivery for the supplies provided in this case. The proof of delivery submitted for this case was for a wrist brace shipped on April 27, 2020. Nothing supporting the delivery of the NMES was included. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the monthly rental charge for a neuromuscular electrical stimulation (NMES) device billed with a September 5, 2020 date of service (DOS).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epogen injections.
You asked the Plan to pre-approve the Epogen injections. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not indicate that the member has tried and failed our preferred step therapy drug Retacrit- for at least two consecutive months, with appropriate dose adjustment.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Epogen injections. Our reviewer says that the requested drug is not considered medically reasonable and necessary based on step therapy rules. Our physician reviewer found the patient is an 80-year-old male with anemia. Epogen was requested. The provided records did not reveal the patient having tried and failed Retacrit for at least 2 months. As both of these medications have the same safety and effectiveness based on current studies comparing them, and as there was no other unique history in the patient's records suggesting otherwise, Retacrit would not likely be less effective or have more risk compared to the requested Epogen. 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 Epogen injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Epogen injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder arthroscopy represented by code 29824 provided on October 20, 2020.
You asked the Plan to pay for code 29824. You say that the medical records support the billing of code 29824. The Plan denied your request. The Plan says the medical records do not support the billing of code 29824.
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 29824 is Arthroscopy, shoulder, surgical; distal
claviculectomy including distal articular surface (Mumford procedure).
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 code 29824. Our reviewer says that the
medical records do not support the billing of code 29824. Our physician reviewer found the medical records
provided does not include sufficient documentation to validate that an Arthroscopy, shoulder, surgical; distal
claviculectomy including distal articular surface (Mumford procedure) was performed on October 20, 2020.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of code 29824 have not been met. Therefore, we decided that the Plan does not
have to pay for the shoulder arthroscopy represented by code 29824 provided on October 20, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 17, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on October 17, 2020.
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 you need LTACH care. The Plan denied
your request. The Plan says rules for LTACH care have not been met.
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 in this case, you were admitted with aspiration pneumonia and endocarditis. You
continue to receive intravenous antibiotics. You also have neurologic deficits that appear irreversible. You
continue to receive acute care services, and these have not been denied. The medical record does not indicate
that you require services that you are not currently receiving but that would be available at the LTACH facility.
The elements of the coverage rules are not satisfied.
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 pay for skilled nursing facility (SNF) care provided from September 25, 2020, to October 24, 2020.
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet Medicare criteria for coverage of 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found 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. This enrollee did 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from September 25, 2020, to October 24, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with sacral fracture and lumbar pelvic fusion. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. He was treated for pain with effect. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at modified independent to stand by assist/supervision level with functional mobility including gait to 328 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98941 and 97032) provided on December 9, 2020.
You asked the Plan to pay for the chiropractic services. You say that you would like reconsideration because you participate with the Plan and Medicare and have billed these services correctly. The Plan denied your request. The Plan says this service was not billed with the required modifier.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 98941 and 97032 is not supported in the record. Specifically, this claim was not billed with the required modifier for chiropractic services. Per the LCA, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment. Based on this information, we decided that Medicare rules for coverage of the chiropractic services have not been met. Therefore, we decided that the Plan does not have to pay for the chiropractic services (98941 and 97032) provided on December 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 17, 2020 to December 14, 2020 by a non-contracted provider.
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 were rendered by a non-contracted provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. 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 office visit provided on November 17, 2020 to December 14, 2020 by a non-contracted provider.