Persius/hicric huggingface dataset:
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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee required minimal assistance with grooming. The enrollee required moderate assistance with transfers and bathing. The enrollee is noted to have limited upper body weight bearing due to arthritis and hand surgeries in past. 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'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 endurance level, weight bearing restrictions, and functional level require 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 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 lab services provided on January 27, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro Motion G custom myoelectric upper
extremity orthosis (L8702).
You asked the Plan to pre-approve the orthosis. You say that the orthosis is necessary. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that services that are necessary, safe and effective, and not
experimental or investigational.
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 orthosis. Our reviewer says that the
orthosis is not medically necessary. Our physician reviewer found the MyoPro Orthosis is not the most
appropriate available supply or level of service for the patient in question considering potential benefits to the
patient. It is not known to be effective, based on scientific evidence, professional standards and expert opinion,
in improving health outcomes. the MyoPro is not in widespread use based on scientific evidence. There is
insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this
patient, improve her hemiparetic arm function, or be safe for long term use. There is insufficient evidence in
the literature that this device will increase her participation in bimanual activities.
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 orthosis have not been met. Therefore, we decided that the Plan does not
have to pre-approve a MyoPro Motion G custom myoelectric upper extremity orthosis (L8702).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examinations (73030 and 73010) provided on
January 28, 2020.
You asked the Plan to pay for the radiologic examinations. You say that you would like reconsideration
because these services have been reported correctly. The Plan denied your request. The Plan says it is not
appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure modifier on the
claim line does not match the diagnosis code.
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 radiologic examinations. Our reviewer says that the ICD-
10-CM Official Guidelines for Coding and Reporting state that it is not appropriate to report an unspecified,
left, right or bilateral diagnosis code when the procedure being performed has a modifier on the claim that does
not match the diagnosis code. Our reviewer found the diagnosis codes submitted on the claim do not specify
right, left or bilateral, therefore CPT codes 73030 RT and 73010 RT are not eligible for reimbursement
consideration.
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 radiologic examinations have not been met. Therefore, we decided that the
Plan does not have to pay for radiologic examinations (73030 and 73010) provided on January 28, 2020.
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 above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was medically stable. The enrollee required moderate to maximum assistance for mobility and activities of daily living. The documentation does not support that the enrollee requires an interdisciplinary approach to rehabilitation care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy rehabilitation 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702), for the enrollee.
You asked the Plan to pre-approve the item. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.
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 item. Our physician reviewer found the requested device has features that are determined deluxe and provide function which replaces rather than improves the function of the enrollee's arm. Medicare guidelines are not met and the request is determined not medically 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 item have not been met. Therefore, we decided that the Plan does not have to pre-approve powered upper extremity range of motion assist device, elbow, wrist, hand, finger, single or double upright(s), includes microprocessor, sensors, all components and accessories, custom fabricated (L8702), for the enrollee.
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 recurrent, metastatic, rectal melanoma. The enrollee underwent resection of the cancer. The enrollee is on bowel rest and parenteral nutrition. The enrollee is also receiving care for post-operative abscesses. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current acute care hospital until such time no acute services are required. 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. You say that you were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says all services obtained from 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 has network providers available who can provide the services at issue in this appeal. 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 the lab services provided on January 15, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on February 22, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the claim for services provided on February 22, 2020 was processed correctly on April 03, 2020. The Plan states there is an exact duplicate claim which was billed for the same date of service and reprocessed on April 15, 2020.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The claim for services provided on February 22, 2020 was processed correctly on April 03, 2020. The Plan states there is an exact duplicate claim which was billed for the same date of service and reprocessed on April 15, 2020. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on February 22, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee is strong and willing to participate in
care at an IRF. You say that an IRF admission would give the enrollee the best opportunity for getting back to
the state of health that allows her to get around on her own. The Plan denied your request. The Plan says the
guidelines for coverage of IRF care have not been 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 the enrollee was medically stable with no evidence of need for supervision by a
physical medicine and rehabilitation facility physician. There is no evidence of a need for acute rehab nursing
care. Functionally, given her moderate to maximum A level with needing a seated rest break does not require
IRF level of therapies. The enrollee may benefit from further physical therapy and occupational therapy, but
does not require an intensive therapy program. IRF admission is not medically necessary based on the
enrollee's current functional status and medical stability.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is still being studied in clinical trials for efficacy in the treatment of knee pain due to osteoarthritis, or in the setting of replacing or significantly deferring total knee arthroplasty.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental and investigational procedure as there are on-going clinical trials to assess efficacy. There is no clinical practice guideline that includes this procedure. She is not enrolled in a clinical trial. Therefore, the request is considered not medically reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve thoracic facet injections.
You asked the Plan to pre-approve the thoracic facet injections. You say that you are in a lot of pain, which is
interfering with your activities of daily living and your quality of life. The Plan denied your request. The Plan
says the documentation provided did not include any imaging studies to show that the enrollee does not have a
non-facet pathology such as a fracture, tumor, infection, or significant deformity. The Plan says that the
enrollee does not meet the guidelines for coverage.
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 thoracic facet injections. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has chronic low back pain and thoracic pain. She has had
transforminal epidural steroid injections. The enrollee has tried several medications. She is using Lidoderm
patches for her thoracic pain. Obtaining imaging of the thoracic spine is necessary prior to any intervention.
There is no imaging of the thoracic spine submitted for review.
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 thoracic facet injections have not been met. Therefore, we decided that the
Plan does not have to pre-approve thoracic facet injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee's medical condition requires admission to an LTACH. The Plan denied your request. The Plan says the requirements for coverage of LTACH care have not been met. The Plan says that the enrollee's needs can safely and effectively be met at a lower level of care.
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 was admitted to the acute care hospital and treated for severe pain following a right knee revision. She was found to have an infection which was treated with IV antibiotics, surgery, and wound care. The enrollee's current needs include therapy and additional IV antibiotics for another month. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. It appears that the enrollee is stable or soon to be stable enough to discharge to a lower level of care such as a skilled nursing facility where PICC line could be monitored and physical therapy could be continued. No other medical needs appear to warrant at least another 25 days of acute care 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis with attachment (L3650, L0637).
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation was insufficient to verify billed codes.
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 does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The physician order does not include the detailed descriptions of the items ordered. In addition, the documentation submitted did not include an itemized shipping/billing invoice to indicate the specific supplies, or proof of delivery. Therefore, the billed supply code cannot be verified. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the shoulder orthosis with attachment (L3650, L0637).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of LTACH care.
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 was admitted to the acute care hospital and treated for sepsis, acute mental status change and COVID-19 pneumonia. Over the course of the hospital stay and after IV antibiotics, pressors, wound management, and monitoring, he appears to be improving clinically with blood pressure normalizing, less coughing and shortness of breath, and no fever. The enrollee's current needs include ongoing basic wound care with wound VAC. The enrollee does not require services at the proposed LTACH that are not already available at the current acute care hospital. It appears that the enrollee is stable or soon to be stable enough to discharge to a lower level of care such as a skilled nursing facility where ongoing wound care and physical therapy could be continued. No other medical needs appear to warrant at least another 25 days of acute care services as the acute infection and encephalopathy has significantly improved. 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.