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 inpatient rehabilitation services are medically necessary for the enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. There is no evidence that the enrollee's ongoing therapy needs cannot be safely met in 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. Our
physician reviewer found that 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The
Plan denied your request. The Plan says a SNF admission is not medically necessary.
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 services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear.
Regarding rehabilitation services, the enrollee received physical therapy (PT) and occupational therapy (OT) in
the SNF prior to the dates in question. At that point, the enrollee was at a standby assist to modified
independent level for bed mobility and transfers. The enrollee required varying assist with activities of daily
living. 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. As a practical matter,
this 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899).
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan
denied your request. The Plan says this is experimental.
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 an Intracept procedure. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe
and effective.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Intracept procedure (22899)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the knee microprocessor (L5828) and accessories (L5845, L5850, L5925).
You asked the Plan to pre-approve the knee microprocessor and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the request exceeds member needs.
The Plan follows Medicare rules. Medicare rules say that the records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications. If a prosthesis is denied as not reasonable and necessary, related additions will also be denied as not 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 the knee microprocessor and accessories. Our reviewer says that the items are not medically necessary. Our physician reviewer found the requested items exceed your medical need as the treating medical provider documentation does not support that you have functional activities that cannot be met with a mechanical K3 knee. 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 knee microprocessor and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee microprocessor (L5828) and accessories (L5845, L5850, L5925).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography services.
You asked the Plan to pre-approve echocardiography services. You say that this testing procedure is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage
have not been met.
The Plan follows Medicare rules. Medicare rules say diagnostic endocardial electrical stimulation (EES), also
called programmed electrical stimulation of the heart, is covered under Medicare when used for patients with
severe cardiac arrhythmias.
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 echocardiography services. Our
reviewer says that the requested trans-thoracic echocardiogram (TTE) is not medically reasonable and
necessary. Our physician reviewer found the enrollee is a 70-year-old woman at the time of her cardiology visit
in September 2021, at which time her trans-thoracic echocardiogram and stress test results were reviewed. 70-
year-old woman at the time of her cardiology visit in September 2021, at which time her trans-thoracic
echocardiogram and stress test results were reviewed. Guidelines would support carrying out the first TTE in
2021 but would not support a need for a repeat TTE in the absence of any significant expected clinical change.
As a result, at this time TTE would not be considered medically appropriate and necessary in this patient's
clinical management.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of echocardiography services have not been met. Therefore, we decided that the
Plan does not have to pre-approve echocardiography services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a Sprint percutaneous nerve stimulator (PNS)
device.
You asked the Plan to pre-approve Sprint PNS. You say that this is covered by Medicare and is medically
necessary. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because this is not a Medicare covered benefit.
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 Sprint PNS. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found there is insufficient evidence to support the use of the requested device for the enrollee's
condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Sprint PNS have not been met. Therefore, we decided that the Plan does not
have to pre-approve use of a Sprint percutaneous nerve stimulator (PNS) device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee
has made progress with transfers and activities of daily living.
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.
Continued SNF services beyond December 15, 2021, were requested. 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 services. Our physician reviewer found that the enrollee does not
require the skilled nursing services of a skilled professional nurse to provide medically necessary treatment
beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral
feedings, or other skilled nursing needs. There has been caregiver training on transfer skills. He is non-weight
bearing to the right lower extremity. His functional level does not require ongoing skilled therapy services with
a qualified therapist to provide medically necessary treatment beyond the last covered date. He does not require
skilled nursing or therapy services on a daily 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 continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81401 and 81403 provided on
November 19, 2020.
You asked the Plan to pay for the laboratory 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 separately payable.
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, we have confirmed that code 81401
for the laboratory services is a column II code to column I code 81439. We have also confirmed that code
81403 for the laboratory services is a column II code to column I code 81439. This claim has not been billed
with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have
not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81401
and 81403 provided on November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic activities (97110) provided on November 17,
2020.
You asked the Plan to pay for the therapeutic activities. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code for
the services rendered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 97110 is not supported in the record. Specifically, this claim was billed by a Nurse
Practitioner and the services were rendered by a PTA. The services of a PTA shall not be billed as services
incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications
of a therapist. Based on this information, we decided that Medicare rules for coverage of the therapeutic
activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities
(97110) provided on November 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgeon services to be provided by an OON
provider.
You asked the Plan to pre-approve the OON oral surgeon services. The Plan denied your request. The Plan says
the enrollee does not have an OON benefit. The Plan says that there is no clinical evidence to support the need
for OON coverage. The Play says that the enrollee's needs can be met in-network.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The requested provider in this case is not a network provider with the Plan. The Plan has network oral
surgeons. We found no exception that would require the Plan to pre-approve services with an OON provider.
Therefore, we decided that the Plan does not have to pre-approve oral surgeon services to be provided by an
OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says the services you require are custodial.
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 services. Our physician reviewer found that you are at a moderate assist level for sit to stand transfers and maximal assist for bed to chair transfers. You have improved back pain. You do not require skilled nursing services of a skilled professional nurse to provide medically necessary treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing needs. Your functional level does not require skilled therapy services of a qualified therapist to medically necessary and reasonable treatment. You do not require skilled services on a daily basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the individual psychotherapy services (90834) to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the psychotherapy services. You say that you have been seeing this provider
for about 5 years and is appealing the denial. The Plan denied your request. The Plan says enrollee's must
receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered.
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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
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. We found no exception that would require
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve
the individual psychotherapy services (90834) to be provided by an out-of-network (OON) provider.
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 inpatient rehabilitation services are necessary to
reduce your risk of falling and hospital readmissions. The Plan denied your request. The Plan says the criteria
for admission to an IRF are not met. You do require routine skilled therapy and outpatient evaluation, but these
services can safely be provided in a less intensive setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for the office visits (99213 and 99214) provided from March
17, 2021, through May 6, 2021.
You asked the Plan to hold you harmless for the office visits. You say that you would like reconsideration
because these services should be paid by the Plan. The Plan denied your request. The Plan says that there is
insufficient information to validate the services rendered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
You were referred for the office visits by a contract provider. The file does not show that the Plan provided
notice that the office visits would not be covered. Under Medicare rules, this means the office visits is
considered approved by the Plan. Therefore, we decided that the Plan has to hold you harmless for the office
visits (99213 and 99214) provided from March 17, 2021, through May 6, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental procedure (D9999).
You asked the Plan to pre-approve the dental procedure. You say that the item was medically necessary. The Plan denied your request. The Plan says this is not a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the dental procedure (D9999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional chiropractic visits of mechanical traction
(97012) and therapeutic exercises (97110).
You asked the Plan to pre-approve the additional visits. You say that you were told by the provider that the
services were denied and you are appealing for the denial of authorization. The Plan denied your request. The
Plan says this request will exceed the Plan benefit frequency limitation of 12 visits per year. The requested
services are not covered under the Plan benefits.
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 enrollee has exhausted the allowed 12 routine chiropractic visits per year. 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 pre-approve 12 additional chiropractic visits of mechanical traction (97012) and
therapeutic exercises (97110)