Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (97530) provided December 16, 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 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 find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows the
services were provided in the home health or hospice setting. There is a more appropriate CPT code to describe
these services in this setting (G0158). 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 (97530) provided December 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hospital bed.

You asked the Plan to pre-approve a hospital bed. You say that the item is 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 a hospital bed may be considered medically necessary when at least one of the following criteria is met:

1. The patient has a medical conditions which requires positioning of the body in ways not feasible with an ordinary bed; or

2. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; or

3. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out; or

4. The patient requires traction equipment, which can only be attached to a hospital bed.

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 hospital bed. Our reviewer says that
the item is not medically necessary. Our physician reviewer found based on the medical records provided there
is documentation that the enrollee meets criteria for a fixed height hospital bed but there is no documentation
that the enrollee meets the criteria for the requested semi-electric hospital bed as records do no document a
need for frequent or immediate changes in body position.

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 hospital bed have not been met. Therefore, we decided that the Plan does not
have to pre-approve a hospital bed.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on June 15, 2020.

You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.

We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on June 15, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99203) provided on May 22, 2020.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the office visit (99203) provided on May 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Hydrogel Spacer.You asked the Plan to pre-approve a Hydrogel Spacer. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 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 Hydrogel Spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found limitations to the study include the lack of blinding and the exclusion of patients who might be at greater risk of rectal toxicity. Additional study is needed to corroborate the findings of the pivotal randomized controlled trial, to identify the factors that increase the risk of rectal toxicity and determine who is likely to benefit from the use of a spacer. The evidence is insufficient to determine the effects of the technology on health outcomes.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 Hydrogel Spacer have not been met.Therefore, we decided that the Plan does not have to pre-approve a Hydrogel Spacer.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
You asked the Plan to pre-approve the requested services. You say that the service is needed to treat back pain. The Plan denied your request. The Plan says the clinical effectiveness has not been demonstrated in peer-reviewed literature.
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 requested services. Our physician reviewer found that you have chronic SI joint pain. You take Diclofenac gel and Tramadol for pain. You previously had RFA of the SI joint with good effect. You underwent a diagnostic SI joint injection and had greater than 50% pain relief. This request is for RFA of the lateral sacral branches. This is an experimental/ investigation procedure. Wide variation in efficacy has been reported in the peer reviewed literature. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) of the sacroiliac (SI) joint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
You asked the Plan to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). You say that the enrollee is suffering and has failed conservative treatment approaches. The Plan denied your request. The Plan says experimental and investigational procedures are not covered by Medicare.
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 insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869). Our reviewer says that the requested items/services are not considered
medically reasonable and necessary in this case. Our physician reviewer found the interlaminar spacer devices are experimental. More research is needed to show safety and efficacy of the device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level (22869) have not been met. Therefore, we decided that the Plan does not have to pre-approve a posterior interspinous decompression spacer procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for the requested CGM.
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 perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, and 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 a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued pain management care with an out-of-network physician.You asked the Plan to pre-approve pain management care. You say that you do not speak English and want to be seen by a provider who speaks Spanish. You also say that this physician understands your case, but if you go to another doctor you will have to start over.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network pain management specialist.Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 pain management care. Our reviewer says that you do not meet the Medicare criteria for continuity of care with this out-of-network provider, and your care can be safely transitioned to an in-network provider at this time. Our physician reviewer found you have chronic mid-thoracic pain. Your treating physician has ordered diagnostic medial branch blocks with guidance. You are Spanish-speaking and have had trigger point injections and medication management with this physician. There are multiple in-network Spanish-speaking pain management specialists within 20 miles of you. This is a common pain intervention procedure. Therefore, continuity of care with an out-of-network physician is 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 pain management care have not been met.Therefore, we decided that the Plan does not have to pre-approve continued pain management care with an out-of-network physician.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided from December 12, 2020, through December 31, 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 the enrollee did not meet criteria for coverage of inpatient skilled nursing facility care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the inpatient skilled nursing facility care provided was not medically necessary. Our physician reviewer found that the enrollee did not require skilled nursing or skilled therapy services on a daily basis. Additionally, as a practical matter, the enrollee did 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) care provided from December 12, 2020, through December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive eye exam provided on January 4, 2021.
You asked the Plan to waive the copayment for the comprehensive eye exam. The Plan denied your request. The Plan says the services were processed under your medical insurance, which resulted in a $25 copayment.
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 $25 copayment for Medicare Covered Vision Services, Specialist's Office. You have been asked to pay a $25 copayment for the comprehensive eye exam. The comprehensive eye exam falls within the Medicare Covered Vision Services, Specialist's Office 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 a comprehensive eye exam provided on January 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services (99202, 72070, 72100) provided November 11, 2020.
You asked the Plan to pay for the chiropractic services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services at issue were not manual manipulation of the spine to correct a subluxation. They are non-covered.
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 records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for chiropractic services (99202, 72070, 72100) provided November 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on July 30, 2020.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.
The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient information to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on July 30, 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 you are appealing with supporting records. 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 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.
While the enrollee does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided at a different level of care. There is not a reasonable expectation that the 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-approve a stair glide provided on December 7, 2020.
You asked the Plan to pre-approve a stair glide. You say that this is medically necessary. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide provided on December 7, 2020.
Appeal type: SNF
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve continued skilled nursing facility services from June 17, 2021 and beyond.
You asked the Plan to pre-approve continued skilled nursing facility services. You say that the enrollee is not quite ready to get back into her home.The Plan denied your request. The Plan says the enrollee is able to ambulate with a walker and stand by assist and therapies can be received as an outpatient.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, it is my opinion that the enrollee no longer qualifies for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating 100 feet and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, AL, LTC).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility services from June 17, 2021 and beyond.