Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from November 7, 2019, through November 9, 2019 with the reported principal diagnosis I21.A1, Myocardial infarction type 2 Iron deficiency anemia secondary to blood loss (chronic).
You asked the Plan to pay for inpatient services provided from November 7, 2019, through November 9, 2019 with the reported principal diagnosis I21.A1, Myocardial infarction type 2 Iron deficiency anemia secondary to blood loss (chronic). The Plan denied your request. The Plan says the provider has reported inpatient hospital services with the incorrect DRG.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with the principal diagnosis I21.A1, Myocardial infarction type 2 Iron deficiency anemia secondary to blood loss (chronic). 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 inpatient services with the reported principal diagnosis I21.A1, Myocardial infarction type 2 Iron deficiency anemia secondary to blood loss (chronic). Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the review indicates that the enrollee was then a 66-year-old male who presented to the facility on
November 7, 2019 for treatment following a fall. To establish the diagnosis of an acute MI, clinical criteria in addition to abnormal biomarkers are required to confirm the occurrence of infarction. There was an increase in troponin up to 0.14; however, the elevation in troponin alone does not validate the diagnosis of acute myocardial infarction. An elevation of troponin can result from myocardial injury other than myocardial infarction or from non-cardiac conditions such as renal failure. In this case, the enrollee presented status post fall and was diagnosed with rhabdomyolysis. The electrocardiogram showed no signs of ischemia and the echocardiogram was without regional wall motion abnormalities. In addition, the enrollee denied chest pain. As a result, there was insufficient objective clinical evidence to validate the diagnosis. The review has determined that the principal diagnosis I21.A1, Myocardial infarction type 2 Iron deficiency anemia secondary to blood loss (chronic) was not supported by the medical records.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient services provided from November 7, 2019, through November 9, 2019 with the reported principal diagnosis I21.A1, Myocardial infarction type 2 Iron deficiency anemia secondary to blood loss (chronic).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a DYNAVOX device or Snap Core tablet speech generating device.
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 the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a speech generating device is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has expressive dysphagia. She attends speech therapy and exhibits slight memory loss. Brain imaging is positive for left hemispheric abnormalities. Per her speech therapy notes, improvement with communication has been proven by meeting her short-term goals with 85 percent accuracy. Based on the above criteria a copy of the speech language therapist's written evaluation and recommendation must be forwarded to the beneficiary's treating practitioner prior to ordering the device, and the records indicate that the enrollee's neurologist does not recommend this communication device. The services are therefore not reasonable or 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a DYNAVOX device or Snap Core tablet speech generating device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Kenevo microprocessor knee prosthesis with foot prosthesis.

You asked the Plan to pre-approve a Kenevo microprocessor knee prosthesis with Tenon foot prosthesis. You say that the requested items are a medical necessity for you. The Plan denied your request. The Plan says rules for durable medical equipment have 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 a Kenevo microprocessor knee prosthesis with Tenon foot prosthesis. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found that the physician and treating medical provider's documentation does not support that you are a K3 ambulator; therefore, the requested durable medical equipment, Kenevo Microprocessor Knee Prosthesis with Tenon Foot Prosthesis, is 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 a Kenevo microprocessor knee prosthesis with Tenon foot prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a Kenevo microprocessor knee prosthesis with foot prosthesis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings, such as skilled nursing facility, outpatient setting, or home health care, can be reviewed.

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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Medicare Part B prescription drug provided on February 25, 2021.

You asked the Plan to waive the coinsurance for the aflibercept injection (J0178). You say that you cannot afford the coinsurance and the injection should have been covered between your health insurance and the Plan insurance. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drug.

You have been asked to pay 20% coinsurance for the aflibercept injection. The aflibercept injection falls within the Medicare Part B prescription drug 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 coinsurance for the Medicare Part B prescription drug provided on February 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for catheter placement services provided on December 29, 2020.

You asked the Plan to pay for the services provided. You say that Medicare rationale is substantiated in the documentation. The Plan denied your request. The Plan says the billed code cannot be verified.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.

The medical records provided do not show that the service billed with the -59 modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for catheter placement services provided on December 29, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 13, 2021 by an out of network (OON) provider.
You asked the Plan to pay for lab test. You say that this testing is covered by Medicare and the Plan should promptly pay this claim. The Plan denied your request. The Plan says the denial of payment for this test is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with the Plan.
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 had network providers available who could have provided 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 laboratory testing provided on February 13, 2021 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission
criteria. The Plan denied your request. The Plan says the enrollee can receive this level of care in another
setting.
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. The enrollee
is currently undergoing treatment at an ACH. The enrollee is not intubated/ventilated. There is no evidence that
the enrollee requires services that are not currently available. As LTACHs and ACHs 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 ACH until such time no acute services are required. The enrollee can then be
transferred/discharged to a lower level of care for any ongoing LTC needs.
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 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 the enrollee needs LTACH services. The Plan denied your request. The Plan says the records do not show that it is medically necessary to be in a LTACH in place of an acute care hospital.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent ambulance transport (A0428) provided on February 26, 2021.
You asked the Plan to pay for the ground mileage and non-emergent ambulance transport. The Plan denied your request. The Plan says the criteria for basic life support non-emergency transport have not been met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
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 ground mileage and non-emergent
ambulance transport. Our reviewer says that the non-emergent ambulance transport did not meet coverage
criteria. Our physician reviewer found the enrollee's presenting symptoms did not meet prudent layperson
criteria for emergency care. The documentation did not support that other means of transport (such as stretcher
van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on
February 26, 2021. Our reviewer found that the documentation did not support that the enrollee needed the
expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can
provide for safe transport. Our physician reviewer also found that the documentation did not support that the
ambulance transport was medically reasonable and necessary 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 the ground mileage and non-emergent ambulance transport have not been met.
Therefore, we decided that the Plan does not have to pay for the ground mileage (A0425) and non-emergent
ambulance transport (A0428) provided on February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on September 25, 2020.
You asked the Plan to pay for the moderate sedation services. 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 supported by the documentation.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 
We find that CPT code 99152 is not supported in the medical record. Specifically, the documentation submitted did not indicate the presence of an independent trained observer to assist in the monitoring of the enrollee's level of consciousness and physiological status. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded 99152 provided on September 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) and a knee brace (L1851) provided on June 5, 2020.
You asked the Plan to pay for a back brace and a knee brace. You say that these items were medically necessary. The Plan denied your request. The Plan says there is not a proof of delivery for these items.
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 proof of delivery for the supplies provided in this case. Though multiple proof of delivery documents were submitted, they showed delivery dates in March and May, while the items at issue were billed for June 5, 2020. 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 a back brace (L0650) and a knee brace (L1851) provided on June 5, 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 these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower 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 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 shortness of breath and pleural
effusions and were discharged home on June 22, 2021. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).

You asked the Plan to preapprove the CGM. You say that you meet criteria as you check your sugar more than
three times a day and do multiple insulin injections. The Plan denied your request. The Plan says you do not
meet all the requirements for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require
frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this
information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we
decided that the Plan does not have to preapprove a continuous glucose monitor (CGM).