Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve facet nerve injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied
your request. The Plan says that the records do not show that the previous procedure improved the enrollee's
pain, or that their daily activities were decreased by 50% in the last six months.
The Plan must follow Medicare rules. The rules say that repeat denervation procedures involving the same joint
will only be considered medically necessary if the patient experienced 50% or more improvement of pain and
improvement in patient specific ADLs documented for at least 6 months.
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 injections. Our reviewer says that
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee meets the criteria for the repeat RFA. The enrollee has MBBs and then RFA with greater
than 80% pain relief. It has been longer than six months, and the pain has returned. The requested procedure 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 injections have been met. Therefore, we decided that the Plan has to preapprove
facet nerve injections 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for the enrollee. The Plan denied your request. The Plan says Medicare criteria for IRF admission are not met.
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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Medicare coverage criteria for IRF care are not met. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on March 12, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says that
the Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for nurse practitioner services provided on March 12, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosisprovided on November 26, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says documentation submitted did not indicate the provider discussed the need for the billed supply code, therefore the billed supply code cannot be verified.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 fileand Medicare rules.The physician notes do not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis provided on November 26, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan doesnot have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that IRF admission is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.The medical records do not show that you require an intensive inpatient rehabilitation therapy program.The medical records do not show that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Medicare coverage criteria are not met. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee requires daily medical management, frequent labs, and rehab therapy to improve strength, gait, and balance.The Plan denied your request. The Plan says the enrollee does not need a multidisciplinary team for 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 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 presented to the acute hospital with a fall resulting in two rib fractures. There was no evidence of pneumothorax or pulmonary contusion on her evaluation. She was treated in the hospital with analgesics, a lidocaine patch and physical therapy. She is weak and deconditioned, and is working with physical and occupational therapy. She is walking with a rolling walker 60 feet with minimum assistance, and is contact guard to minimum assist for transfers and activities of daily living. Cognition is intact but with decreased insight. She is medically stable. 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 enrollee does require physical therapy and occupational therapy services, but she does not require an intensive inpatient rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from theintensive rehabilitation therapy program provided in an inpatient rehabilitation facilityWe 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 beenmet. Therefore, we decided that the Plan does not have to pre-approveacute 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 IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee's care is not complex, and does not need a team of providers for 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 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 presented to the acute hospital with an acute stroke. She did not get thrombolysis or an embolectomy. She was treated in the hospital with antiplatelet therapy. She is weak on the left side and is deconditioned with dysphagia. She is non-ambulatory and requires assistance to sit up in bed. She is noted to have decreased exercise tolerance with therapy treatment. She is medically stable. 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 enrollee does require physical therapy and occupational therapy services, but she does not require an intensive inpatient rehabilitation therapy program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services (CPT 73100) provided to the enrollee on March 14, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says both services were supposed, however, a modifier indicating the service is separate and distinct was not used.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 73100 is "radiologic examination, wrist; 2 views."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 billing the same CPT code on the same date of service requires a modifier for distinct services.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 forradiology services (CPT 73100) provided to the enrollee on March 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for inpatient admission for the enrollee.
You asked the Plan to provide coverage for inpatient admission. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria for inpatient care are not met.
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 provide coverage for inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the medical records from the emergency room visit, the enrollee was stable and did not require at least a 2-midnight hospital stay. Additional testing such as ultrasound and consultation with ENT could have been completed under observation status. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient admission have not been met. Therefore, we decided that the Plan does not have to provide coverage for inpatient admission for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy services.
You asked the Plan to pre-approve the additional physical therapy services. The Plan denied your request. The Plan says the enrollee does not meet criteria for additional physical therapy visits.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy service. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The enrollee has had prior therapy for this condition and staff also assists patient in her facility. She has been observed ambulating 75 feet multiple times per week. She had had extensive education on her condition and safety. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.
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 physical therapy service have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy services
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care could be received in another setting.
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. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. The enrollee may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that the enrollee's functional status requires an intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a wireless capsule endoscopy (WCE) provided on January 20, 2020.
You asked the Plan to pay for a wireless capsule endoscopy. You say that the enrollee previously had an esophagogastroduodenoscopy. The Plan denied your request. The Plan says an upper and lower gastrointestinal study should be performed prior to a wireless capsule endoscopy.
The Plan must follow Medicare rules. Medicare rules say that WCE is limited to those patients who have undergone upper GI endoscopy and colonoscopy and these tests have failed to reveal a source of bleeding. We looked at the file and Medicare rules. The record does not show that the enrollee has had a colonoscopy. Based on this information, we decided that Medicare rules for coverage of a wireless capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a wireless capsule endoscopy (WCE) provided on January 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided from May 23, 2019 to January 20, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided from May 23, 2019 to January 20, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on January 31, 2020 and February 1, 2020.
You asked the Plan to waive the copayment for the ambulance transports. You say that you should not be responsible for these charges. The Plan denied your request. The Plan says that the claims processed 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 $250 copayment for each trip in an ambulance. You have been asked to pay a $250 copayment for each of the ambulance transports. The ambulance transports fall within the each trip in an ambulance 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 ambulance transports provided on January 31, 2020 and February 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services provided on February 27, 2020.
You asked the Plan to waive the copayment for the physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received physical therapy services on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $30 copayment for Outpatient rehabilitation services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physical therapy services on February 27, 2020. You have been asked to pay a $30 copayment for the physical therapy services. The physical therapy services fall within the Outpatient rehabilitation services 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 physical therapy services provided on February 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says you do not meet the criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.We looked at the file and Medicare rules. The records show that you are not testing your blood glucose levels four or more times per day. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).