Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean expandable controller, attendant control, access harness, electrical connection, power seat elevation system and other accessories for the enrollee.You asked the Plan to pre-approvethe accessories. You say that this is medically necessary.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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendantcontrol. The enrollee's upper extremity strength and function are sufficient for the enrollee to control any power options through their own individual switches. The K0108 memory seat is to improve the enrollee's ability to complete a pressure relief and appears to exceed the enrollee's need, and does not serve a primarily medical purpose. The power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature and are therefore consideredmedically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met.Therefore, we decided that the Plan does not have to pre-approvean expandable controller, attendant control, access harness, electrical connection, power seat elevation system and other accessories for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist office visit (99203) on
February 12, 2020, and an echocardiography procedure (93306) performed on February 27, 2020.
You asked the Plan to waive the copayments for a specialist office visit and an echocardiography procedure.
You say that these charges are not right. The Plan denied your request. The Plan says the correct copayments
were applied.
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 $50
copayment for physician specialist services and a $40 copayment for diagnostic procedures and tests.
You have been asked to pay a $50 copayment for a specialist office visit and a $40 copayment for an
echocardiography procedure. A specialist office visit falls within the "Physician/Practitioner services, including
doctor's office visits" benefit category. An echocardiography procedure falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" 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 copayments
for a specialist office visit (99203) on February 12, 2020, and an echocardiography procedure (93306)
performed on February 27, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approveeight (8) physical therapy visits (CPT Code 97110).You asked the Plan to pre-approvethe services. You say that you would like to see the member get the highest amount of physical therapy possible.The Plan denied your request. The Plan says the services are not necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deteriorationof the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally accepted as specific and effective therapy for the patient's condition. The patient has had prior therapy and the patient's functional and cognitive level do not support that the patient requires the ongoing additional therapy with the unique skills of a professional therapist to safely and effectively provide treatmentor that the services can be safely and effectively performed only by a therapist,or under the supervision of a therapist. The patient's functional needs can be met with staff care and assist and caregiver education. The additional 8 sessions requested are excessive 
and the documentation does not reveal the patient needs these sessionswith the specialized skill, knowledge and judgment of a qualified therapist  to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approveeight (8) physical therapy visits (CPT Code 97110)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT Code 64624).
You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says this procedure is considered experimental and investigational when used to treat knee pain.
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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental/ investigational and is the subject of ongoing clinical trials. You are not enrolled in a clinical trial. Therefore, the request is considered not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (CPT Code 64624).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long-term acute care hospital (LTACH).You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysit is not medically necessary to transfer care to the LTACH.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 you are currently undergoing treatment at an acute care hospital for a large ischemic stroke, treated with a thrombectomy that was complicated by hemorrhage. You were intubated/ventilated and subsequently received a tracheotomy and feeding tube. You remain on a ventilator with poor neurologic status. It is unclear that you can be weaned from the ventilator or decannulated. As LTACHs and ACHs are licensed to providethe same level of care, there is no advantage in transferring the enrollee to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long-termcare 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 Plandoes not havetopre-approveadmission to a long-term acute care hospital (LTACH).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82248, 85027, 80053, and 80177 and the travel allowance services coded P9604 provided on September 20, 2019.
You asked the Plan to pay for the laboratory services and the travel allowance services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 codes 82248, 85027, 80053, 80177, and P9604 are not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81. In addition, the submitted documentation did not include a valid physician order/lab requisition form or medical records signed by the ordering physician. Based on this information, we decided that Medicare rules for coverage of the laboratory services and the travel allowance services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82248, 85027, 80053, and 80177 and the travel allowance services coded P9604 provided on September 20, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that the member needs home health care aide due to multiple health issues. The Plan denied your request. The Plan says the services are not necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 home health aide services. Our physician reviewer found the records do not show that skilled nursing (SN) services are required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration. There are no complex wounds, new enteral feedings or other SN need. The records do not show that skilled therapy is needed to effectively provide treatment, care, and/or services in order to improve the patient's level of function, or to establish/perform a maintenance program to maintain the patient's level of function and/or prevent deterioration. As the patient does not require skilled therapy or skilled nursing services the patient does not meet the definition of home health aide services per Section 50.2 and the request for home health aide services are not reasonable and necessary to the treatment of the patient's illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. 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 repair of right hip fracture. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee orthosis (L1851)You asked the Plan to pre-approvethe orthosis. You say that the claim is necessary.The Plan denied your request. The Plan says the records show no instability with objective testing, and no recent surgery or injury.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 orthosis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record does not show that the beneficiary has had recent injury to or a surgical procedure on the knee(s). In addition, the record does not show knee instability is documented by examination of the beneficiary and objective description of joint laxity.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthosis have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee orthosis (L1851)
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient surgical services provided on February 24, 2020.You asked the Plan to waive the copayment foroutpatient surgical services. You say that you already met your out of pocket maximum on this date of service.The Plan denied your request. The Plan says you have an out of pocket maximum of $3200 and you did not meet your maximum until June 25, 2020.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 $325 copayment for outpatient services. You have been asked to pay a $325 copayment for outpatient surgical services. The outpatient surgical services fallwithin the outpatient surgical services 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. You did not meet yourout of pocketmaximum until June 25, 2020. This claim was processed before April 2020.Therefore, we decided that the Plan does not have to waive the copayment foroutpatient surgical services provided on February 24, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee from July 5, 2019, to October 4, 2019 and billed under codes 83036 and P9604.
You asked the Plan to pay for codes 83036 and P9604. You say that this claim should be paid. The Plan denied your request. The Plan says the place of service reported should be where the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed due to an issue with the POS code reported. Medicare rules for coverage of codes 83036 and P9604 have not been met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee from July 5, 2019, to October 4, 2019 and billed under codes 83036, and P9604.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on February 14, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that you paid this by mistake. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.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 $235 copayment for ambulance services. You have been asked to pay a $235 copayment for an ambulance trip. The correct copayment has been applied to the services that were provided. An ambulancetrip falls within the ambulance services 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 an ambulance trip provided by a participating provider on February 14, 2020
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on
the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for
COVID 19. 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 long-term care 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 long-term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 1, 2020, by an OON
provider.
You asked the Plan to pay for nursing facility care. You say that these medically necessary services were
provided to the enrollee in good faith. The Plan denied your request. The Plan says rules for payment have not
been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 on July 1, 2020, by
an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Intracept procedure for the enrollee.You asked the Planto pre-approvethe procedure. You say that this is medically necessary.The Plandenied your request. The Plansaysmedical studies have not shown that this procedure is helpful for treatment of the health problem.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 procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure remains experimental for the treatment of lower back pain. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of theprocedure have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Intracept procedure for the enrollee.