Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided after 12:06 pm on
March 31, 2019 to April 1, 2019.
You asked the Plan to pay for these services. You say that the inpatient hospital care provided was medically
necessary. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized
by 12:06 p.m. on March 31, 2019 and subsequent care was post stabilization care, not approved in compliance
with the health plan's authorization procedures. The Plan has paid for all emergent care up to the point of
stability.
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 these services. Our reviewer says that the
inpatient services provided do not meet criteria for coverage. Our physician reviewer found the enrollee arrived
at the Emergency Department (ED) on March 29, 2019 by ambulance from her long-term care
facility for melena. In the ED, she was in no distress and her vital signs were stable. She was transfused with 2
units of Packed Red Blood Cells and 1 unit of platelets.
She was admitted to the ICU, monitored and underwent an Esophagogastroduodenoscopy where a gastric ulcer
with visible vessel was found and clipped. There was no active bleeding found after and her hemoglobin
stabilized. The review has determined that as of 12:06 p.m. on March 31, 2019, the enrollee was
hemodynamically stable and appropriate for ambulance transport with monitoring to a plan facility for
continued inpatient level of care services. The review has determined that the treating physician did not
document (in the physician notes, on a form, or in an order) that the patient was not stable for transfer on any
dates of service. Post-stabilization of care services at the non-Plan facility after 12:06 p.m. on March 31, 2019
through 10:10 p.m. on April 1, 2019 was not medically necessary and 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 these services have not been met. Therefore, we decided that the Plan does not
have to pay for the inpatient hospital care provided after 12:06 pm on March 31, 2019 to April 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 9,
2019 to October 28, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says valid proof of
delivery was not submitted.
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 shows that the Plan made several attempts to obtain the proof of delivery documentation for the
items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in
this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a
tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the
diabetic supplies provided to the enrollee from August 9, 2019 to October 28, 2019.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says IRF care 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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our physician reviewer found that the documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. Our physician reviewer found that the enrollee may benefit from and participate in additional physical and occupational therapy, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 services are necessary. The Plan
denied your request. The Plan says the care required can be provided in the current inpatient hospital.
Therefore, coverage criteria has 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 is currently undergoing treatment at an acute care hospital (ACH)
following cardiac surgery for atherosclerosis and valvular disease. As of January 10, 2020 the enrollee was
showing signs of successful ventilator weaning. As LTACHs and ACHs are licensed to provide the same level
of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower
level of care for any ongoing long term care (LTC) needs.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a laparoscopic hysterectomy (58552).
You asked the Plan to pre-approve a laparoscopic hysterectomy. You say that the service is necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
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 a laparoscopic hysterectomy. Our reviewer says that the requested service is considered medically reasonable and necessary in this case. Our physician reviewer found the plan requires a magnetic resonance imaging (MRI) or computed tomography (CT) or diagnostic laparoscopy prior to hysterectomy for pelvic pain but neither is an absolute routine part of the pelvic pain workup. It is medically reasonable, safe, and necessary that the enrollee has access to a hysterectomy for treatment of pelvic pain. 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 laparoscopic hysterectomy have been met. Therefore, we decided that the Plan has to pre-approve a laparoscopic hysterectomy (58552).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that Prolia is medically necessary. The Plan denied your request. The Plan says a trial of bisphosphonates must be documented before drugs like Prolia can be considered.
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 Prolia. Our reviewer says that coverage criteria has not been met. Our physician reviewer found plan criteria requires failure or ineffective response to a minimum of 12 months of therapy with a bisphosphonate. The record does not show a trial of oral or IV Bisphosphonates or any reason why such a trial would be unsafe or ineffective for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99497 provided on May 16, 2019.
You asked the Plan to pay for CPT code 99497. You say that you would like the plan to reconsider their denial
of payment. The Plan denied your request. The Plan says the services are not covered.
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 99497 is Advance care planning including the
explanation and discussion of advance directives such as standard forms (with completion of such forms, when
performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the
patient, family member(s), and/or surrogate.
We find that CPT code 99497 is not supported in the medical record. Specifically, CPT code 99497 is a time
based code. In order to bill CPT code 99497, the documentation must note that the first 30 minutes were faceto-
face with the patient, family member(s), and/or surrogate for advance care planning. The progress note for
May 16, 2019 does not note how much of the time spent was for advanced care planning. As such, the provided
documentation does not support the billing of CPT code 99497. Based on this information, we decided that
Medicare rules for coverage of CPT code 99497 have not been met. Therefore, we decided that the Plan does
not have to pay for CPT code 99497 provided on May 16, 2019.
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 enrollee needs intensive rehab care and requires a hospital setting due to his medical conditions. The Plan denied your request. The Plan says there is no need for an interdisciplinary rehab program.
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 enrollee was admitted to the hospital on 1/6/2020 due to acute on chronic systolic congestive heart failure and cellulitis. This enrollee is 85 years old and fluid overloaded on admit due to acute CHF status post diuresis. History is also notable for prior ORIF right hip following fracture. The member is now stable, but remains debilitated and functionally, is minimal assist for mobility, ambulation, and exhibits poor endurance. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound/skin and O2 care, and daily therapy can be provided at a SNF. In this case, the member is mostly MIN assist for mobility & MAX assist for lower body ADL's and a less intensive, longer duration of therapy will allow for measurable gains to be achieved within a predicted period. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.
You asked the Plan to pay for intermittent limb compression device. You say that this service was medically necessary and should be covered by the plan. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare for the prevention of blood clots
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. The file does not show that the enrollee has lymphedema and/ or chronic venous insufficiency with venous stasis ulcers. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services provided to the enrollee from May 16, 2019 to May 17, 2019 and billed under code 99152.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met. The Plan says that code 99152 is defined as moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status; initial 15 minutes of intra service time. The documentation submitted did not include documentation of the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; therefore, the billed service cannot be verified. Of note, an independent trained observer is someone other than the physician performing the services. The Plan notes additional information was requested from the provider, but those requests were not responded to.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code and when necessary provide specific documentation to support the services billed. In this case, code 99152 is not support by the records provided as the documentation does not indicate the presence of an independent assistant or observer. Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pay for sedation services provided to the enrollee from May 16, 2019 to May 17, 2019 and billed under code 99152.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that it is unsafe for you to be sent home alone at this time and could result in readmission to the hospital, or worse. The Plan denied your request. The Plan says the enrollee does not require complex daily nursing care that must be provided in a skilled nursing facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee admitted to acute care with rapid atrial fibrillation and electrolyte abnormalities. Our physician reviewer found that the enrollee was transferred to an outside hospital for a coronary artery bypass grafting on January 6, 2020. Our physician reviewer found that the enrollee did well post-operatively and completed a course of IV antibiotics. Our physician reviewer found that the enrollee is now on oral medicines only, including oral medication for pain control. Our physician reviewer found that the enrollee has a past medical history significant for coronary artery disease with stenting 1995, gastric bypass, Diabetes Mellitus with neuropathy, and sleep apnea on Continuous Positive Airway Pressure (CPAP). Our physician reviewer found that the enrollee's prior level of function was living alone in a one story home and being independent with mobility and activities of daily living. Our physician reviewer found that the enrollee's current level of function is standby assist with grooming and toileting, negotiating 6 stairs with minimal assist, ambulating 70 feet with a rest break with contact guard assist, and transferring with standby assist.
Our physician reviewer found that the records do not support that the enrollee needs daily physical and occupational therapy. Our physician reviewer found that there are no noted daily skilled complex nursing needs. Our physician reviewer found that the enrollee is ambulating household distances and requires little assistance with mobility and transfers. Our physician reviewer found that, while the enrollee may benefit from continuing physical and occupational therapy, the records do not support the need for daily therapy. 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 pre-approve skilled nursing facility (SNF) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code S9343 provided from May 11, 2019 to May 24, 2019.
You asked the Plan to pay for CPT code S9343. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. In this case, CPT code S9343 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for CPT code S9343 provided from May 11, 2019 to May 24, 2019.
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 enrollee would be best served by an IRF stay. The Plan denied your request. The Plan says the enrollee is medically stable and can be treated in the SNF.
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 enrollee was seen in the hospital on 1/4/2020 due to generalized weakness. She was found to have low sodium and potassium levels with constipation. The member was also managed for a urinary tract infection. Her acute medical conditions stabilized with appropriate management. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin care, and daily therapy can be provided at a SNF. In this case, the member is mostly MODERATE/MIN assist for functional transfers and ADL's and a less intensive, longer duration of therapy will allow the member to achieve measurable gains within a predicted period. 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: 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 the SNF services. You say that you would benefit from short-term rehabilitation. The Plan denied your request. The Plan says the enrollee does not meet the criteria for SNF coverage because the required care is non-skilled.
The Plan must follow Medicare rules. The rules say that Medicare pays for 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications and insulin. Our physician reviewer found that the enrollee had stable vital signs. Our physician reviewer found that the enrollee received physical and occupational therapy in the acute hospital. Our physician reviewer found that the enrollee was at contact guard to stand by assist levels with functional mobility, including gait up to 150 feet with a rolling walker. Our physician reviewer found that the enrollee required varying assist levels with activities of daily living. Our physician reviewer found that there are no identifiable skilled nursing service needs. Our physician reviewer found that there are identifiable skilled therapy service needs, but that they are not required 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.