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

We decided that the Plan does not have to pre-approve inpatient skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that a SNF admission is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of a 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 SNF care. Our reviewer says that inpatient skilled nursing facility care is not medically necessary. Our physician reviewer found that at the time of the prior admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. According to the most recent therapy documentation the enrollee no longer required any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living.

The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis. He did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however his function had plateaued and he did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services.

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 inpatient skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care billed with principal diagnosis code N17.9.

You asked the Plan to pay for the inpatient services as billed. You say that this was correctly billed and should be paid at the reported DRG. The Plan denied your request. The Plan says the reported principal diagnosis for this admission is not supported, and as such, payment cannot be made at the billed DRG rate.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal diagnosis.

In this case, you billed the services provided with principal diagnosis code N17.9, which is defined as acute kidney failure, unspecified. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient services as billed. Our reviewer says that the documentation does not support the reporting of acute kidney failure as the principal diagnosis code. Our physician reviewer found the enrollee presented to the emergency department and was found to have a urinary tract infection with acute kidney injury. She was treated with intravenous (IV) antibiotics and IV fluids. The review indicates that the medical documentation did not support the reporting of N17.9 (acute kidney failure, unspecified) as the principal diagnosis for this admission.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the billed DRG. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care billed with principal diagnosis code N17.9.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you required contact guard assistance to stand up. You required minimal assistance for lower body dressing. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you require an intensive rehabilitation therapy program. Your 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Other
Decision: Favorable

We decided that the Plan has to pre-approve a left heart catheterization for the enrollee.

You asked the Plan to pre-approve the procedure. You say that there is chest pain due to coronary artery disease. The Plan denied your request. The Plan says that there is no evidence of covered indications for this procedure.

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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has some risk factors (age, hypertension) for CAD but there is no report of unstable angina symptoms. She had a resting echocardiogram which showed normal let ventricular function and has not had cardiac stress testing. Due to the enrollee's advanced age and typical angina symptoms, she would be considered to have an intermediate risk of coronary artery disease based on appropriate use criteria for cardiac catherization. As there is no CMS NCD or LCD with specific indications and rules regarding cardiac catheterization applicable here, the section 1862 (a) rule applies, which is based on medically reasonable and appropriate care. As such, the published appropriate use criteria for catheterization do provide latitude for individual clinical judgement in this instance and the use of cardiac catherization would therefore meet CMS coverage rules in this clinical situation.

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 procedure have been met. Therefore, we decided that the Plan has to pre-approve a left heart catheterization for the enrollee.

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: Favorable

We decided that the Plan has to pre-approve lateral L2-3 arthrodesis.

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that the records do not show documented spinal stenosis.

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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found you were being treated for L2-3 retrolisthesis. There is past history of L3-L5 transforaminal lumbar interbody fusion with noted persistent pain. There is documented adjacent disc pathology at L2-3. MRI demonstrates 5mm retrolisthesis of L2 on L3, further progressed since prior study (without spondylolysis) consistent with adjacent segment disease; bilateral L2-L3 neural foramina stenosis without definite nerve root compression; subtle segment instability at L2-L3 with Modic type I end plate changes. Dynamic x-rays also noted retrolisthesis of L2 on L3 measuring 5.7mm. The documentation demonstrates a trial and failure of the guideline-indicated conservative care modalities. In light of the persistent symptoms corroborated by imaging studies showing retrolisthesis/spondylolisthesis/instability of the lumbar spine at L2-3 with failure of conservative measures, the requested lateral L2-3 arthrodesis is medically reasonable and 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 the services have been met. Therefore, we decided that the Plan has to pre-approve lateral L2-3 arthrodesis.

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 lab work provided by an out of network (OON) provider.

You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider. The Plan says that these services could have been provided in-network.

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 lab work provided 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 is currently undergoing treatment at an acute care hospital for end-stage pulmonary fibrosis. The enrollee is not intubated/ventilated. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.

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 admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 you required minimal assistance with transfers. The documentation does not support that you require 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 have no complex wound care, IV antibiotics, or other skilled nursing need. 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 admission 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI.

You asked the Plan to waive the copayment for the MRI. You say that the original MRI was supposed to be for three places, so you had to return. You say that you would not have two copayments if it had been done correctly. The Plan denied your request. The Plan says the copayment applied correctly.

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 $180 copayment for advanced imaging services at an in-network PCP's office, specialist's office or freestanding radiological facility.

You have been asked to pay a $180 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRI.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle x-ray (73610), transportation (R0070), and set-up (Q0092).

You asked the Plan to pay for an ankle x-ray, transportation, and set-up. You say that this was medically necessary due to the pandemic. The Plan denied your request. The Plan says this was not billed with the required modifier.

The Plan must follow Medicare rules. Medicare rules say that that providers or suppliers shall use anatomic modifiers (e.g. RT, LT, FA, F1-F9, TA, T1-T9, E1-E4) and report procedures with differing modifiers on individual claim lines when appropriate.

We looked at the file and Medicare rules. The record shows that the x-ray at issue was of the left ankle, but it was not reported with the correct anatomic modifier to indicate the left side (LT). Based on this information, we decided that Medicare rules for coverage of an ankle x-ray, transportation, and set-up have not been met. Therefore, we decided that the Plan does not have to pay for an ankle x-ray (73610), transportation (R0070), and set-up (Q0092).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an echocardiography provided by an out of network (OON) provider.

You asked the Plan to pay for an echocardiography. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is also out-of-network. You say there are in-network providers available for these services.

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 an echocardiography provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital care billed with principal diagnosis code N17.9.

You asked the Plan to pay for the inpatient hospital care. You say that the claim was billed correctly with the correct principal diagnosis. The Plan denied your request. The Plan says that the reported principal diagnosis is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal diagnosis code.

In this case, you billed the services provided with principal diagnosis code N17.9, defined as acute kidney failure, unspecified. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient hospital care. Our reviewer says that the documentation does support the reporting of the principal diagnosis of acute kidney failure. Our physician reviewer found the patient is a 79-year-old male who was diagnosed with acute kidney failure related to hypovolemia and dehydration. Creatinine (Cr) was 2.59 on presentation. Recent Cr was 1.24 and estimated baseline less than 1.0 from the records. The increase in Cr was more than 1.5 which meets criteria for acute kidney failure (N17.9).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital care billed with principal diagnosis code N17.9.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF care.

You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found you required moderate assistance to sit up, lie down and sit down. The documentation does not support that you require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. Your 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-approve IRF care.
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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee refused to stand up or get out of bed. The documentation does not support that the enrollee requires an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires an intensive rehabilitation therapy program. 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-approve acute inpatient rehabilitation facility (IRF) admission and services.