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 will need physical therapy for health reasons and the pain in your hip. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

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 hypocalcemia and hyperkalemia associated with end stage renal disease. Your medical conditions 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. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 18, 2020.
You asked the Plan to pay for therapeutic exercises. You say that this service was not available from a network provider. The Plan denied your request. The Plan says this service was not billed correctly.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that this service was provided in a home health setting. There is a more appropriate code for this service. Based on this information, we decided that Medicare rules for coverage of therapeutic exercises have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic exercises (97110) provided on September 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network provider.

You asked the Plan to pre-approve the out-of-network office visit. You say that you have been treated by this doctor since June 26, 2019. You say that your physical and mental health condition should be considered and uninterrupted treatment with your doctor should be approved. The Plan denied your request. The Plan says you must receive your care from a network provider.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit to be provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standard manual wheelchair for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary to help the enrollee be more active. The Plan denied your request. The Plan says there is no documentation that needs cannot be met with the current walker.
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 wheelchair. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal a mobility deficit that significantly impairs MRADLs in the home, and is not ameliorated by a walker, cane, manual wheelchair. The documentation does not reveal that the home is appropriate for the requested wheelchair. The documentation does not reveal that the requested wheelchair will significantly improve MRADL participation in the home, or that the enrollee and/or caregiver can safely propel the requested wheelchair. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a standard manual wheelchair for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on April 21, 2020.
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 procedure code 97110 is 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were rendered in the home setting and there is a more appropriate code for these services. 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 pay for the physical therapy services rendered on April 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro orthotic device.

You asked the Plan to pre-approve the MyoPro orthotic device. 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 MyoPro orthotic device. Our reviewer says that the requested device is not considered medically reasonable and necessary in this case. Our physician reviewer found that the MyoPro orthosis is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro orthosis 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 enrollee, improve hemiparetic arm function, or be safe for long-term use. There is insufficient evidence in the literature that this device will increase 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 MyoPro orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro orthotic device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for transluminal angioplasty provided from March 18, 2021, to March 19, 2021.
You asked the Plan to waive the copayment for transluminal angioplasty. You say that you disagree with the denial of coverage. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers.
You received transluminal angioplasty at an outpatient hospital facility from March 18, 2021, to March 19, 2021. Transluminal angioplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for transluminal angioplasty. Transluminal angioplasty falls within the outpatient surgery, including services provided at hospital facilities and ambulatory surgical centers 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 transluminal angioplasty provided from March 18, 2021, to March 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99214 x 3) and an ophthalmological medical eye exam and evaluation (92014 x 3) to be rendered by the out of network (OON) provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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.
We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99214 x 3) and an ophthalmological medical eye exam and evaluation (92014 x 3) to be rendered by the out of network (OON) provider.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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.

The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillectomy services coded 31225 and related services provided on October 13, 2020.
You asked the Plan to pay for the maxillectomy and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as 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. In this case, the CPT Code Manual definition of code 31225 is maxillectomy; without orbital exenteration. We find that CPT code 31225 is not supported in the medical record. Specifically, code 31225 has a status indicator of "C". A status indicator of C means that this code is an inpatient only code and is only payable when submitted as inpatient. This claim was submitted as an outpatient claim. This means these services are not
payable as billed. Based on this information, we decided that Medicare rules for coverage of the maxillectomy and related services have not been met. Therefore, we decided that the Plan does not have to pay for the maxillectomy services coded 31225 and related services provided on October 13, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a referral to a tertiary level pain management specialist.
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 that the tertiary level of care is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically necessary.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the tertiary level of care is medically necessary. Our physician reviewer found you have pancreatic cancer that
has metastasized after a Whipple procedure. You have had chemotherapy and radiation therapy. You have
altered anatomy after the Whipple procedure with both kidney and pulmonary complications. You have
complex issues that require tertiary pain management. The tertiary level of care is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to preapprove
a referral to a tertiary level pain management specialist.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a necessity because the enrollee cannot get out of a chair or up off the floor. The Plan denied your request. The Plan says rules for SNF care have not been met because the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee has no identifiable skilled nursing service needs. The enrollee does have identifiable skilled therapy service needs; however, the enrollee does not require skilled nursing or therapy services on a daily basis. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient mental health care.

You asked the Plan to pre-approve the inpatient care. The Plan denied your request. The Plan says this is not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient care. Our reviewer says that the requested inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found that the enrollee does not require inpatient mental health treatment beyond the dates in question as he is not a danger to himself or others and does not have any auditory or visual hallucinations or behavioral issues. It does not appear that active treatment is taking place beyond the date in question. It does not appear that the services for are reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the inpatient care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient mental health care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound coded 76706 provided on April 7, 2021.
You asked the Plan to pay for the ultrasound. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the services billed are not separately payable.

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 76706 is ultrasound, abdominal aorta, real time with
image documentation, screening study for abdominal aortic aneurysm (AAA).

We find that CPT code 76706 is not supported in the medical record. Specifically, this code was billed on the same date of service as code 76770 by the same provider. Code 76770 was previously approved and paid by the Plan. This means that code 76706 is not separately payable as billed. Based on this information, we decided that Medicare rules for coverage of the ultrasound have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound coded 76706 provided on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-preferred brand diabetes supplies.
You asked the Plan to pre-approve non-preferred items. The Plan denied your request. The Plan says the requested strips are not a preferred brand.
The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred.
The requested brand of test strips and glucometer in this case is not a network provider with the Plan. The Plan has preferred brands available.
We found no exception that would require the Plan to pre-approve non-preferred items. Therefore, we decided that the Plan does not have to pre-approve non-preferred brand diabetes supplies.
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. The Plan denied your request. The Plan says IRF admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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. The enrollee was admitted for surgical treatment of aortic stenosis. Medical conditions are stable. There are no
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient 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 inpatient rehabilitation facility (IRF) admission and services.