Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve left knee arthroscopy knee with meniscectomy for the enrollee.

You asked the Plan to pre-approve these services. You say that a trial of formal physical therapy would be
contraindicated. The Plan denied your request. The Plan says that that there is no documentation of your having
had physical therapy or being unable to tolerate such activity.

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 requested services are considered medically reasonable and necessary in this case. The records reveal that
the patient has magnetic resonance imaging (MRI) evidence of a meniscal tear and there is catching and
locking of the knee. Physical therapy is contraindicated in this case as there is locking of the knee with the
meniscal tear documented. Surgery is the next appropriate treatment option at this time. Our physician reviewer
found that the enrollee's condition meets Medicare criteria for these 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 these services have been met. Therefore, we decided that the Plan has to preapprove
left knee arthroscopy knee with meniscectomy 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.

You asked the Plan to pre-approve IRF care. You say that the records provided support the need for care in an
IRF. The Plan denied your request. The Plan says the records provided do not show that the enrollee needs an
intensive program with a team of health care professionals and doctors that specialize in complex medical
needs, as well as rehab.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for neck pain and has cervical spine decompression and fusion. The enrollee's 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and
services.

You asked the Plan to pay for IRF care. You say that the IRF stay is medically necessary. The Plan denied your
request. The Plan says services can be provided at the current level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 pay for 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 long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the clinical documentation provided
supports the need for LTACH care. The Plan denied your request. The Plan says the guidelines for LTACH
care have not been met. The Plan says that the information provided does not show that the enrollee has
completed his full course of care in the hospital. The Plan says that the enrollee can stay in the hospital to finish
his treatments.

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 there is no documentation provided necessitating admission to a LTACH. The
enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at
the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
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 reconsideration because the member will require an additional three to four weeks of care. The Plan denied your request. The Plan says the member does not require nursing care greater than 6 hours per day and does not have wounds with heavy drainage requiring several changes throughout the day.
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 there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: 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 when the medical records were originally sent it showed that the enrollee was not ready for therapy. You say that the enrollee is now doing physical therapy and doctors are wanting to put her in IRF because they feel it is better and safer. The Plan denied your request. The Plan says the guidelines for IRF care have not been met. The Plan says that the enrollee could receive care 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 in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical treatment of a tib-fib fracture after a fall. The enrollee's 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
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 claim was billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.
We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the replacement of the semi-electric hospital bed (E0184, E0260, E0310).
You asked the Plan to pre-approve the replacement of the semi-electric hospital bed. You say that the member's bed no longer functions as it should. The Plan denied your request. The Plan says the member received a bed in 2018 within the reasonable useful lifetime.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of an item in no case can be less than 5 years. During the reasonable useful lifetime, Medicare does not cover replacement of medically necessary equipment. We looked at the file and Medicare rules. In this case, the documentation indicates that the enrollee's semi-electric hospital bed is less than five years old and within the reasonable useful lifetime of an item. Based on this information, we decided that Medicare rules for coverage of the replacement of the semi-electric hospital
bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the replacement of the semi-electric hospital bed (E0184, E0260, E0310).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chair lift.

You asked the Plan to pre-approve the chair lift. You say that you would like reconsideration because this chair lift is medically necessary. The Plan denied your request. The Plan says the documentation does not show that the member is unable to stand up from a regular armchair or any chair in the home.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.

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 chair lift. Our reviewer says that the criteria for the requested lift chair have not beet met. Our physician reviewer found the member does not have objective evidence of severe arthritis of the hip or knee or have a severe neuromuscular disease. The documentation does not support that this would improve or stop deterioration of the member's condition. The documentation does not indicate the member is completely unable to stand up from a regular armchair or any chair in the home.

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 chair lift have not been met. Therefore, we decided that the Plan does not have to pre-approve the chair lift.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97110) provided August 29, 2020.

You asked the Plan to pay for the therapy services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the CPT code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show the services were provided in the home setting. There is a more appropriate CPT code to describe the billed services (G0151). Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (97110) provided August 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardio screening provided on December 11, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says there is no evidence of a relationship with the ordering physician and the enrollee.

The Plan follows Medicare rules. The rules explicitly say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation.

We looked at the file and the rules. In this case, there are insufficient medical records to show that the results of the testing would be used to treat the enrollee's specific medical problem. The testing panel at issue in this appeal was requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardio screening provided on December 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99153) provided on September 18, 2020.

You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says this code is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting.

We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the anesthesia services (99153) provided on September 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha Sureclick for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Repatha Sureclick for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
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 would benefit from IRF care to optimize her level of function prior to returning home. You say that the enrollee requires interdisciplinary therapy care of physical and occupational therapies, as well as 24-hour nursing care for daily labs and vital monitoring due to her medical decline and physical state from being hospitalized for over 2 months. The Plan denied your request. The Plan says the documentation shows that the enrollee's medical condition is stable. The Plan says that the enrollee does not meet the criteria for coverage of IRF care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a Whipple procedure for ampullary cancer and was treated for pulmonary embolism, pneumonia and an abdominal abscess. The enrollee's 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from November 30, 2020, to December 2, 2020.

You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stable for transfer.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient care. Our reviewer says that the requested inpatient care is not medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is an 86-year-old male who arrived at the emergency department by ambulance with chest pain and was admitted to the hospital with COPD exacerbation and acute on chronic heart failure, which were treated appropriately. Cardiology noted that he no longer had chest pain, was not in any distress, and was hemodynamically stable on November 30, 2020. There was no documentation suggesting that the enrollee was not stable for transfer at any point in time. Based on the provided documentation, the enrollee was stable for transfer around 1:00 p.m. on November 30, 2020.

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 pay for the inpatient care provided from November 30, 2020, to December 2, 2020.