Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSNF care.You asked the Plan to pre-approveSNF care. You say that the stay was 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 paysfor care in a SNF when the four factors listed above 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 you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse required to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not have complex wound care or other ongoing SNF level SN need. Your functional leveldoes not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment only in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on 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 pre-approveSNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Bilevel Positive Airway Pressure (BiPAP) device. 
 
You asked the Plan to pre-approve a BiPAP device. You say that the BiPAP device is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of the BiPAP 
device. 
 
The Plan follows Medicare rules. Medicare rules say that an E0470 device is covered for those beneficiaries 
with obstructive sleep apnea (OSA) who meet criteria. 
 
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 a BiPAP device. Our reviewer says that 
a BiPAP device is not medically necessary at this time. Our physician reviewer found the compliance report 
shows usage at least four hours per night for only 15.6% of nights, which does not meet Medicare criteria, and 
is not enough usage to be effective. The medical records do not show that there has been a visit with the 
provider to address the compliance issue. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a BiPAP device have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Bilevel Positive Airway Pressure (BiPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower spine joint injection for the enrollee. 
 
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your 
request. The Plan says physical therapy should be attempted to the extent tolerated. 
 
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 injection. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found in this case, there has not been at least three months of moderate to severe pain that have responded to 
conservative care, the pain is associated with radiculopathy, and there is no documentation indicating that the 
facet joint is the main source of pain. The requested procedure is not medically necessary or reasonable. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a lower spine joint injection for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on February 24, 2020.You asked the Planto waive the copayment for an inpatient hospital stay. You say that the surgery was cancelled. You say that you should not have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan mustdisclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment per day for days 1-5. There is no charge for additional days for inpatient hospital care. You have been asked to pay a $325 copayment for one day of an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient hospital stay provided by a participating provider on February 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve nine (9) additional direct skilled nursing services of a 
registered nurse (RN) in the home health or hospice setting, each 15 minutes (CPT Code G0299 X9). 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 services. Our physician reviewer 
found the records do not show that additional skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance 
program to maintain your condition and/or prevent deterioration. The documentation does not support that you 
required skilled nursing (SN) for complex wound care, new enteral feedings or a new tracheostomy tube. You 
are independent in diabetic medication administration. You have been educated on safety and disease 
management. Your comorbidities are chronic and do not require the ongoing professional skills of a nurse for 
management. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve nine (9) additional direct skilled nursing services of a RN in the home health or hospice 
setting, each 15 minutes (CPT Code G0299 X9).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF 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 IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
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 patient's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's 
medical status does not currently require intensive physician and nursing oversight only in an IRF. The patient 
may benefit from multiple therapies such as physical and occupational therapy but the documentation does not 
support that the patient's functional status requires or can tolerate an 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (CPT 72170) provided to the enrollee on 
April 26, 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 an appropriate modifier was not used. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 72170 
has a bundled relationship with code 73502 and cannot be paid as billed without the appropriate modifier. This 
code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not 
been met. Therefore, we decided that the Plan does not have to pay for radiology services (CPT 72170) 
provided to the enrollee on April 26, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for 
the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your 
request. The Plan says it does not appear that a transition to a higher level of rehab therapy would be 
appropriate at this time. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described above. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was treated in skilled nursing facility and is now living at home. There are no identified problems that need 
inpatient medical management. 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. There is not a reasonable expectation that this enrollee will be able to 
fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Computed Tomography (CT) of the Lumbar Spine (72131) 
provided November 12, 2019. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the claim cannot be processed until an Explanation of Benefits is received from the 
primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has requested an 
explanation of benefits from the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the CT scan until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for Computed Tomography (CT) of the Lumbar Spine (72131) provided November 
12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (CPT 11921) provided to the enrollee on 
December 20, 2019. 
 
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 Current Procedural Terminology (CPT) code 11921 remains not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 11921 is "Tattooing, intradermal introduction of 
insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm." 
 
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 the medical 
records provided do not include documentation of Tattooing, intradermal introduction of insoluble opaque 
pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm being performed on 
December 20, 2019, therefore this service cannot be verified. The records state that the enrollee was there on 
December 20, 2019 for bilateral micropigmentation, but the doctor did not document in her procedural note the 
size of the area she performed this service on. 
 
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 surgical services (CPT 11921) provided to the enrollee on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the member has cancer and will die if they do not gain their strength.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 requestto 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 based on the documentation provided, the health plan's denial should be upheld. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can 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 not been met.Therefore, we decided that the Plan does not have to pre-approveacute IRF admission and services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services (vitamin B-1) provided on June 2, 2020.You asked the Plan to waive the copayment forthe services. You say that you weren't supposed to be charged because of COVID-19.The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.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 $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for the services. The services fall within the laboratory tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This costsharing 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 forlaboratory services (vitamin B-1) provided on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair (PWC).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a PWC is covered when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
you do not meet the criteria for coverage. Our physician reviewer found the submitted records show that you
have a personal mobility deficit but the records are not clear that this mobility limitation impairs your ability to
complete mobility-related activities of daily living (MRADLs) in the home. Your mobility deficit is currently
helped by a prosthesis. The records do not show that the mobility deficit cannot be helped by a manual
wheelchair or walker. The Group 2 PWC is therefore not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Group 2 power wheelchair (PWC).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 16 skilled nursing visits and 24 home health aide visits. 
 
You asked the Plan to pre-approve the home health services. The Plan denied your request. The Plan says home 
health services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the requested home health services are not medically reasonable and necessary. Our physician 
reviewer found that the records do not show that skilled nursing services are required to effectively provide 
treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a 
maintenance program to maintain the patient's condition and/or prevent deterioration. The enrollee's current 
medical conditions/needs, including vaginal suppository, do not require the ongoing skills of a professional 
nurse. The enrollee has had education in her medical conditions and the documentation indicates she is also 
capable of inserting her own vaginal suppository. As the documentation does not reveal a need for home skilled 
nursing or home skilled therapy services, the services do not meet the definition of home health aide services. 
Home health aide services are not reasonable and necessary for treatment of the patient's illness or injury. 
 
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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 16 skilled nursing visits and 24 home health aide visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician's services provided from February 2, 2020, through 
July 2, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 
authorization is required. 
 
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 
services at issue. 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 for physician's services provided from February 2, 2020, through 
July 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 heavy duty power wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied 
your request. The Plan says there are no body measurements provided showing the enrollee would not fit in the 
previously approved group 1 power wheelchair. 
 
The Plan must follow Medicare rules. Medicare rules say that the definition of the requested power wheelchair 
K0824 is "POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT 
WEIGHT CAPACITY 301 TO 450 POUNDS."  
 
Your weight is under 301 pounds. Based on this information, we decided that Medicare rules for coverage of 
the wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 
heavy duty power wheelchair.