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

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that these services are medically necessary.The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for acute on chronic renal failure and cellulitis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. The Plan denied your request. The Plan says the enrollee's needs are custodial, and she does not require daily skilled therapy.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 services. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications, had stable vital signs, and was treated for pain with effect. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee was at a contact guard assist level with functional mobility. Although there are identifiable skilled therapy service needs, the enrollee does not require skilled nursing or therapy services on a daily basis. She does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the DecisionDx melanoma testing.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the testing was not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found that no provider records have been submitted for review. Therefore, there is no evidence to support that the provided services were medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx melanoma testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe problem focused limited oral evaluation, cone beam CT capture and interpretation, osseous, osteoperiosteal, or cartilage graft, and extraction provided .You asked the Plan to pay forthe problem focused limited oral evaluation, cone beam CT capture and interpretation, osseous, osteoperiosteal, or cartilage graft, and extraction. You say that you feel that these services should be covered.The Plan denied your request. The Plan says these services were rendered by a provider who is not a Medicare enrolled provider and as such is not eligible for reimbursement from Medicare for services rendered.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. Your Plandoes not cover dental services, nor does Medicare, and even though these services were provided due to an injury, they are considered dental in nature and are not covered. These are dental services that are not covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pay forthe problem focused limited oral evaluation, cone beam CT capture and interpretation, osseous, osteoperiosteal, or cartilage graft, and extraction provided
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forophthalmological services provided .You asked the Plan to pay forthe ophthalmological services. The Plan denied your request. 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.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 Plandid not pre-approve the ophthalmological services.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 forophthalmological services provided
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (A0425, A0427) provided to the enrollee.

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 on this date of service, the enrollee was in an inpatient hospital status.

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 the denied codes is:

HCPCS A0425:

Ground mileage, per statute mile

HCPCS A0427:

Ambulance service, advanced life support, emergency transport, level 1 (als 1 - emergency)

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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found the
documentation submitted confirm the enrollee was inpatient status. Therefore, this service cannot be confirmed 
as performed.

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 pay for ambulance services (A0425, A0427) provided to the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTAC admission criteria. The Plan denied your request. The Plan says it is not medically necessary for a transfer of care to a LTACH.

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 does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our reviewer found that 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. Our physician reviewer also found that the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for family medicine services (CPT 99483).

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 99483 (1 unit) 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 99483 is "Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home, with all of the following required elements: Cognition-focused evaluation including a pertinent history and examination; Medical decision making of moderate or high complexity; Functional assessment (eg, basic and instrumental activities of daily living), including decision-making capacity; Use of standardized instruments for staging of dementia (eg, functional assessment staging test [FAST], clinical dementia rating [CDR]); Medication reconciliation and review for high-risk medications; Evaluation for neuropsychiatric and behavioral symptoms, including depression, including use of standardized screening instrument(s); Evaluation of safety (eg, home), including motor vehicle operation; Identification of caregiver(s), caregiver knowledge, caregiver needs, social supports, and the willingness of caregiver to take on caregiving tasks; Development, updating or revision, or review of an Advance Care Plan; Creation of a written care plan, including initial plans to address any neuropsychiatric symptoms, neuro-cognitive symptoms, functional limitations, and referral to community resources as needed (eg, rehabilitation services, adult day programs, support groups) shared with the patient and/or caregiver with initial education and support. Typically, 50 minutes are spent face-to-face with the patient and/or family or caregiver."

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 documentation did not include enough documentation to confirm this procedure code has been confirmed. The documentation should be clear on all the criteria for reporting this procedure code to confirm services were performed.

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 family medicine services (CPT 99483) provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea fluid circulating cold pad with pump.You asked the Plan to pre-approvethe fluid circulating cold pad. You say that the requested item would reduce inflammation and swelling, as well as promote healing after the enrollee's upcoming rotator cuff surgery.The Plan denied your request. The Plan says the item being requested is not medically necessary according to Medicare guidelines.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare rules state that fluid circulating cold pads with pumps, represented by current procedural terminology (CPT) code E0218, will be denied as not reasonable and necessary.Therefore, we decided that the Plan does not have to pre-approvea fluid circulating cold pad with pump
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dialysis services provided.You asked the Plan to pay forthe dialysis services. You say that the services are not hospice related.The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date ofelection to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay forthe dialysis services provided
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care providedYou asked the Plan to pay foracute inpatient hospital care. You say that the Plan should pay this claim.The Plan denied your request. The Plan says that the enrollee's services could have been provided in another setting.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided from .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 toopen the case again, we will send you a letter.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment.

You asked the Plan to pay for the durable medical equipment. You say that you would like reconsideration because these codes are payable individually and not included in other services or supplies. The Plan denied your request. The Plan says these services can only be billed to the Durable Medical Equipment Regional Carrier.

The Plan must follow Medicare rules. Medicare rules say that a Skilled Nursing Facility (SNF) may not bill for DME furnished to its Part B inpatients or outpatients unless it is qualified as a supplier.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the durable medical equipment have not been met. Specifically, there is no evidence that this SNF is a qualified DME supplier which is enrolled with the NSC. Therefore, we decided that the Plan does not have to pay for the durable medical equipment.
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 acute inpatient rehab is needed to address a decline in function. The Plan denied your request. The Plan says this request 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 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. Our reviewer found that the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. Our physician reviewer also found that 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 acute IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forlevocarnitine (J1955), thiamine (J3411), pyridoxine (J3415) and unclassified drugs (J3490) provided .You asked the Plan to pay forthe injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coder 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 injections. Our reviewer says that CPT codes J1955, J3411, J3415 and J3490 do not meet criteria for billing or reimbursement consideration.Our reviewer found the medical records provided statea pre-filled syringe containing a nutri-pharmaceutical blend/mix was injected;therefore, these drugs cannot be separately reported;therefore, these services cannot be verified.  The medical records submitted do not include documentation to support billing 8 units of J3490.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theinjections have not been met.Therefore, we decided that the Plan does not have to pay forlevocarnitine (J1955), thiamine (J3411), pyridoxine (J3415) and unclassified drugs (J3490) provided
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services (80061, 81225, 81226, 81227) provided .You asked the Plan to pay forthe lab services. You say that the services were medically necessary due to COVID-19.The Plan denied your request. The Plan says the tests at issue were not COVID-19 tests and there are insufficient medical records to support the need for this testing.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception ofthe few tests listed above, are not covered.The test at issue in this appeal were requested solely for screening purposes. No office visit notes were provided to support the medical necessity for these tests. The plan made multiple requests for additional records and none were provided. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forlab services (80061, 81225, 81226, 81227) provided