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

We decided that the Plan does not have to pre-approve acute IRF admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not require the intensive level of care required to qualify for an inpatient rehab facility stay.
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 physician reviewer found that the enrollee is at contact guard assist for bed mobility, standby assist for ambulation with a rolling walker, and independent for bed transfers. 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. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. His medical issues appear controlled. The enrollee may benefit and participate in additional physical and occupational therapy, but his high functional level 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 for the enrollee.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/14/20 for elective C3-C7 Posterior Fusion. His hospital course was complicated by post-operative delirium requiring Zyprexa. Now, the enrollee is showing no signs of sepsis and/or toxicity. The enrollee is hemodynamically stable and afebrile. There are mobility and activities of daily living deficits, and the enrollee warrants minimal/moderate assist overall for bed mobility and transfers while maintaining neutral spine precautions. Hemgogram is stable. He is ambulating 20' with a rolling walker. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate to minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted to acute care on 1/9/20 for stroke-like symptoms. He had orthostatic hypotension, and this improved on Florinef. The enrollee was noted to have postural symptoms causing a transient ischemic attack (TIA), with imaging evidence of moderate carotid and intracranial stenosis. Co-morbidities include insulin-dependent diabetes, and atrial fibrillation on Eliquis. The enrollee is hemodynamically stable, and is warranting minimal/moderate assist for activities of daily living and transfers. Therapy reports there may be a somatic symptom disorder due to severe caregiver stress. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate to minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy can allow for measurable gains to be attained 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing rendered to the enrollee on August 9, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare. The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication.
Therefore, we decided that the Plan does not have to pay for the 4Kscore testing rendered to the enrollee on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary exercise bike.
You asked the Plan to pre-approve a stationary exercise bike. You say that you would like to build strength in your legs so that daily activities are easier. The Plan denied your request. The Plan says Medicare does not cover exercise equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Home exercise/ PT equipment that can be obtained without a prescription is considered to be an over the counter supply, is not considered DME, and is therefore, ineligible for coverage. Therefore, we decided that the Plan does not have to pre-approve a stationary exercise bike.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for a portable oxygen concentrator.
You asked the Plan to pre-approve a backup battery. You say that the battery does not last long enough to get to a doctor appointment and back. The Plan denied your request. The Plan says backup batteries are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. Equipment that is presumptively non-medical in nature and used primarily and customarily for a non-medical purpose, even though the item may have some remote medically-related use, is not considered DME. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare will not pay separately or make any additional payment for backup equipment. Therefore, we decided that the Plan does not have to pre-approve a backup battery for a portable oxygen concentrator.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (S9363) provided to the enrollee on July 1, 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 this is an invalid procedure code for this service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the definition of HCPCS code S9363 is "Home infusion therapy, anti-spasmotic therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem." We find that CPT code S9363 is not supported in the medical record. Specifically, this code has a status indicator of "I." This means that it is an invalid procedure code for this service. 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 home infusion therapy services (S9363) provided to the enrollee on July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five additional visits for chiropractic care.
You asked the Plan to pre-approve five additional visits for chiropractic care. You say that you are requesting additional chiropractic care to alleviate pain from arthritis. The Plan denied your request. The Plan says the goal for a patient is to return to the highest level of function realistically attainable and within the context of the disability. The skills of the chiropractor may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, then transferring their care to a caregiver and HEP (Home Exercise Program) which would be expected in the approved visits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover chiropractic maintenance care. 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 five additional visits for chiropractic care. Our reviewer says that the requested additional chiropractic care does not meet criteria for coverage. Our physician reviewer found that despite the chiropractic treatments provided, there is no evidence that treatment cures or relieves your complaints of pain, or that you have exhibited significant objective improvement, significant changes in treatment, that resolution will occur or that you will achieve any further benefit from care. There is no evidence that you exhibit significant dysfunction with activities of daily living and are unable to perform some form of home therapy, independently, for ache and pain complaints, rather than the continuation of chiropractic intervention. The chiropractic treatments are considered to be maintenance treatments and are not supported or allowed per Medicare guidelines. Additionally, the chiropractic treatments are medically unnecessary, exceed a reasonable prognosis, are not supported by the submitted documentation and are not supported by Medicare guidelines, as stated above. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of five additional visits for chiropractic care have not been met. Therefore, we decided that the Plan does not have to pre-approve five additional visits for chiropractic care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by an out of network provider.
You asked the Plan to pay for an ultrasound. You say that you had services done in the same facility with the same doctor. 
You say that you were under the impression that these services were covered. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the provider is also out-of-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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on July 9, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99601, CPT 99602) provided to the enrollee
on June 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are not
valid.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.
We looked at the file and Medicare rules. CPT codes 99601 and 99602 are assigned a status indicator of "I"
under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare
uses another code for reporting of, and payment for, these services. 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 the services (CPT 99601, CPT 99602) provided to the enrollee on June 5, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head without dye (70450) provided on June 17, 2019.
You asked the Plan to pay for a CT scan of the head without dye. You say that this service should be paid. The Plan denied your request. The Plan says this service is included in a service paid on a previous claim.
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 70450 (a CT scan of the head without dye) has a Column One/Column Two relationship with code 70470 (a CT scan of the head with and without dye) and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claims submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a computed tomography (CT) scan of the head without dye (70450) provided on June 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stress test provided on August 13, 2019.
You asked the Plan to waive the copayment for the stress test. You say that this was a non-radiology diagnostic service. You say that the copayment should be $0. 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 $40 for each diagnostic radiology service. Diagnostic radiology services include, but are not limited to, ultrasound, MRI scans, PET scans, nuclear medicine studies, CT scans, cardiac stress tests, SPECT, myelogram, cystogram, and angiogram. You have been asked to pay a $40 copayment for the stress test. The stress test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that a cardiovascular stress test was performed. 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 stress test provided on August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRAF/ATP7B/ROS proto-oncogene testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this is 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 pre-approve the testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the coverage criteria for BRAF gene analysis were met in this case, as the enrollee does not have a diagnosis of malignant melanoma, non-small cell lung cancer, hairy cell leukemia, or metastatic colorectal cancer. The documentation does not support that the coverage criteria for ROS proto-oncogene testing were met in this case, as the enrollee does not have a diagnosis of non-small cell lung cancer. The documentation does not support that the coverage criteria for ATP7B testing were met in this case, as the enrollee does not have symptoms of Wilson's disease. 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 pre-approve BRAF/ATP7B/ROS proto-oncogene testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a blood glucose monitor (E2100), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on June 18, 2019 to September 6, 2019.
You asked the Plan to pay for a blood glucose monitor, test strips, lancets, calibrator solution, and a lancing device. You say that these items should be covered. The Plan denied your request. The Plan says the delivery ticket submitted did not include the carrier's tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery ticket.
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 physician order and 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. Specifically, the delivery ticket and the proof of delivery did not corroborate one another in regards to an order number and carrier. Therefore, we decided that the Plan does not have to pay for a blood glucose monitor (E2100), test strips (A4253), lancets (A4259), calibrator solution (A4256), and a lancing device (A4258) provided on June 18, 2019 to September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for (CPT E2100), (CPT Code A4253), (CPT Code A4259), (CPT Code A4256) and (CPT Code A4258) provided to the enrollee from July 11, 2019 through September 29, 2019.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. HCPCS Code(s) E2100 - NU, KS, A4253 - NU, KS, KL (2 Units), A4259 - KS, KL, A4256 - KS, KL (3 Units), A4258 - KS, KL - dates of service July 11, 2019 - September 29, 2019. The Delivery Ticket submitted did not include the carrier's tracking number, nor did the Proof of Delivery include an order number or details to corroborate the Delivery Ticket submitted. Therefore, we decided that the Plan does not have to pay for (CPT E2100), (CPT Code A4253), (CPT Code A4259), (CPT Code A4256) and (CPT Code A4258) provided to the enrollee from July 11, 2019 through September 29, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that skilled physical therapy will increase functional mobility and endurance. The Plan denied your request. The Plan says that skilled services do not need to be provided daily in an inpatient 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 SNF care. Our physician reviewer found that you are status-post acute care admission for metabolic encephalopathy and stroke versus seizure. You require oversight of her medical conditions and medication management. You are at risk for secondary complications of immobility such as pressure ulcers and contractures. You have not returned to your prior level of function. You require both daily skilled therapy and nursing services. You are unable to perform essential activities of daily living such as bed mobility without assistance of more than one person. Your condition would be expected to deteriorate with services provided on a less than daily basis. There is a reasonable expectation of a reduction in burden of care to a level requiring assistance of only one person with a goal of a successful return to the community through the SNF level care being requested. 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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.