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 the enrollee currently meets IRF admission criteria under Medicare guidelines. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require 15 hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care such as skilled nursing 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from September 1, 2019 through October 7, 2019 by an out-of-network provider. You asked the Plan to pay for the medical services. You say that the claim should be paid. The Plan denied your request. The Plan says the provider is not Medicare certified as an inpatient hospital. The Plan states the care is not eligible for coverage under the Medicare Advantage plan, there is no network deficiency, and this is not an emergency situation. 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 provider is not an acute inpatient care facility or long term acute care hospital (LTACH) certified facility. They are not a participating Medicare facility. There is no inpatient hospice care under the Medicare Advantage Plan. The transfer to this provider was for palliative and hospice care. Care could have continued to be provided at the ACH or provided at a lower level of care such as home or inpatient hospice under Traditional Medicare. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided from September 1, 2019 through October 7, 2019 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for admission to an inpatient hospital for the enrollee. You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says that this was approved as outpatient. 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 pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found per the reviewed documentation she had replacement of a fractured pacemaker electrode and was monitored. She was discharged home on 6/30/20 when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for admission to an inpatient hospital for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is not medically stable to be transferred at this time.
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 short-term acute care hospital can provide for all the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. The enrollee does not appear to be stable to transfer at this time based on the provided medical records. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium (CPT 75571)
You asked the Plan to pre-approve the scan. You say that this is medically necessary to check for blockages. The Plan denied your request. The Plan says quantitative calcium scoring is not a covered service and will be denied as not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CPT 75571 is not a covered code. The requested scan, which includes quantitative calcium scoring, is coded with CPT 75571. Based on this information, we decided that Medicare rules for coverage of the scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the heart with quantitative evaluation of coronary calcium (CPT 75571)
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for revascularization services (37224) provided on December 13, 2019.
You asked the Plan to pay for the revascularization services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 37224 is revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. 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 revascularization services. Our reviewer says that CPT code 37224 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative report does not clarify that the balloon was not used for the insertion of the thrombectomy device. 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 revascularization services have not been met. Therefore, we decided that the Plan does not have to pay for revascularization services (37224) provided on December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant ER 600 MG Tablet, for the enrollee.
You asked the Plan to pre-approve the Part B drug. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the enrollee's plan has Part A and Part B coverage, with no Part D drug coverage. The plan states that Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Horizant ER 600 MG Tablet, for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that this is medically necessary. The Plan denied your request. The Plan says your needs could be met at a lower level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the medical records provided, you do not require skilled nursing services. While you need skilled therapy services, you do not need these services on a daily basis. You do not require the services on an inpatient basis in a skilled nursing facility setting. Services in the long-term care facility on a part time basis appear appropriate in this case. 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 skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve2 Evenity injections (J3111). You asked the Plan to pre-approve2 Evenity injections. You say that the services are necessary.The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 2 Evenity injections. Our reviewer says that the services are medically necessary. Our physician reviewer found the review has determined that the documentation supports that the Evenity is medically reasonable and necessary and safe and effective for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 Evenity injections have been met.Therefore, we decided that the Plan has to pre-approve2 Evenity injections (J3111).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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve total electric hospital bed. You say that you need this bed so your spouse does not injure herself while taking care of you. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because total electric hospital beds are not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that total electric hospital beds are not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says skilled services are those that are reasonable and necessary for the treatment of a patient's illness or injury, and are consistent with the nature and severity of the individual's illness or injury.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy (97039), neuromuscular re-education (97112), and the mechanical traction therapy (97012) provided February 3, 2020 to March 10, 2020.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy. Additionally, the services were rendered by an out of network provider. The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay forthe physical therapy (97039), neuromuscular re-education (97112), and the mechanical traction therapy (97012) provided February 3, 2020 to March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a complex cystometrogram (51729), voiding pressure studies (51797), electromyography studies (51784) and complex uroflowmetry (51741) provided on October 22, 2019.
You asked the Plan to pay for the studies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the services 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 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 studies. Our reviewer says that CPT code 51729 does not meet criteria for billing or reimbursement consideration because the medical records provided do not include documentation of a Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique being performed. CPT code 51797 does not meet criteria for billing or reimbursement consideration because the medical records provided do not include documentation of a Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure) being performed. Our reviewer found CPT code 51784 does not meet criteria for billing or reimbursement consideration because the medical records provided do not include documentation of an Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique being performed. CPT code 51741 does not meet criteria for billing or reimbursement consideration because the medical records provided do not include documentation of a Complex uroflowmetry (eg, calibrated electronic equipment) being performed.
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 studies have not been met. Therefore, we decided that the Plan does not have to pay for a complex cystometrogram (51729), voiding pressure studies (51797), electromyography studies (51784) and complex uroflowmetry (51741) provided on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Watchman device procedure (33340, 93355).You asked the Plan to pre-approve the Watchman device procedure. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 Watchman device procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records you have paroxysmal atrial fibrillation with aCHADS2 score of only one, that is lower than the cutoff of 2 to qualify for Medicare coverage for this procedure. In addition, nosebleeds are not characterized, they are usually effectively treated with nasal cauterization and are generally not a contraindication for long term anticoagulation. Overall the records do not support the medical necessity for placement of a Watchman device and 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 the Watchman device procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve the Watchman device procedure (33340, 93355).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the clinical information indicates that needs can be met safely in the current hospital setting.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 the admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.