Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapy services (procedure code 97530) provided to the enrollee on December 4, 2019.
You asked the Plan to pay for the services. You say that the medical records support the code as billed. The Plan denied your request. The Plan says the denied code remains not supported.
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 97530 is "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes." We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation supports a place of service of 12 - Home. CPT 97530 is an inappropriate code to report for services in the home. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report for in home services. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for therapy services (procedure code 97530) provided to the enrollee on December 4, 2019.
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 requested admission to an IRF does not meet criteria.
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 enrollee's nursing, medical and rehabilitation needs do not require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical
condition does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from
additional physical and occupational therapy, but the documentation does not reveal that this therapy must be
only on an intensive level 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care following the left
shoulder joint replacement surgery (CPT code 23470).
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says you are medically stable and has been provided medical clearance
to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 23470 is not
listed on the Centers for Medicare & Medicaid Services (CMS) Inpatient Only List. The Plan states the
procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation
provided to support the expectation you will require a greater than two (2) midnight stay. The Plan states if you
experience any peri- or post-operative complications, reconsideration for inpatient level of care can be
performed on concurrent review with updated clinical information. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this
case. Our physician reviewer found there is no expectation that you require hospital services that would likely
cross two (2) midnights for this typically ambulatory procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the acute inpatient hospital care following the left shoulder joint replacement
surgery (CPT code 23470).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve advanced imaging services to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 facility in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve advanced imaging services to be rendered by the out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says that currently, there is a lack of adequately designed trials in the peer-reviewed literature concerning the use of radiofrequency ablation as definitive treatment for chronic 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure which is the subject of ongoing clinical trials. Therefore, the request is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve extra heavy-duty wheelchair (CPT code K0007).
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the Medicare rules for CPT code K0007 is not covered. The Plan states they approved you to receive a heavy-duty wheelchair which is appropriate for anyone in the 250 to 299 pound range.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Review of the file shows that your last documented weight was 293 pounds. The Medicare rules states that an extra heavy-duty wheelchair (K0007) is covered if the beneficiary weighs more than 300 pounds. Therefore, we decided that the Plan does not have to pre-approve extra heavy-duty wheelchair (CPT code K0007).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stationary bicycle.
You asked the Plan to pre-approve the item. You say that this is medically necessary. The Plan denied your request. The Plan says this device exceeds your medical needs with additional technology features that are not reasonable or necessary.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a stationary bicycle.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits.
You asked the Plan to pre-approve the additional PT visits. You say that it is felt that additional PT would provide significant benefit. The Plan denied your request. The Plan says no further PT is necessary in this case.
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 additional PT visits.
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the available records, the patient appears to have improved with therapy to the point of being able to manage ambulating without a crutch with strength that is within the normal range. Further skilled therapy at this point does not appear to be likely to achieve any significant further improvement in the patient's symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper endoscopy procedure.
You asked the Plan to pre-approve the upper endoscopy. You say that it is felt this is needed to assess treatment. The Plan denied your request. The Plan says records did not include a detailed history that shows this test is needed.
The Plan follows Medicare rules. Medicare rules say that endoscopy may be considered reasonable and necessary for the indications listed 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 the upper endoscopy. Our reviewer says that the requested endoscopy is not shown to be reasonable and necessary at this time. Our physician reviewer found the record indicates that the enrollee had an endoscopy three weeks prior that demonstrated a tight stricture with ulceration. The record indicates that the enrollee was to be treated with twice daily proton pump inhibitor and histamine blocker. The record does not indicate that there has been subsequent follow up. The provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. 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 upper endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper endoscopy procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar-sacral orthosis (LSO) to be provided by a chiropractor.
You asked the Plan to pre-approve LSO. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this item is correct, because this item is not covered by Medicare or the Plan when supplied by a chiropractor.
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 pre-approve a lumbar-sacral orthosis (LSO) to be provided by a chiropractor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 20, 2020, by an OON
provider.
You asked the Plan to pay for the office visit. You say that the service was medically necessary. The Plan
denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 office visit provided on July 20, 2020, 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 for the enrollee.
You asked the Plan to pre-approve SNF services. You say that SNF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found the enrollee does not require a transfer to
a SNF from the inpatient rehabilitation facility (IRF). The documentation does not reveal evidence of complex
wound care or other skilled nursing SNF need. The enrollee's functional level does not require skilled therapy
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively
provide medically necessary and reasonable treatment in a SNF. The enrollee does not require skilled nursing
or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical
matter the enrollee needs can be met in the current IRF setting until the enrollee is ready for a safe discharge
into the community or home.
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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a step stool with railing.

You asked the Plan to pre-approve a step stool with railing. You say that you are currently in physical therapy
for balance training. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve a step stool with railing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the video electroencephalogram (EEG) monitoring
(95700, 95715, 95712, 95709) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the video EEG monitoring. You say that this facility prevents
hospitalization during testing, lowering cost. The provider offers mobility services at the enrollee's home while
monitoring from the office. This also allow's safe social distancing during COVID-19 pandemic. 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 video electroencephalogram (EEG) monitoring (95700, 95715, 95712, 95709) to be provided by an out-ofnetwork
(OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998)
provided on May 12, 2021.

You asked the Plan to pay for the ambulance service. You say that you thought you were experiencing a heart
attack. You say that your wife called an ambulance. You say that you were advised everything was normal.
You also say that paramedic advised you should follow up with your doctor. The Plan denied your request. The
Plan says no transport services were provided. The Plan also says that there is not benefit unless a transport
takes place.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.

The ambulance company did not provide transport services on May 12, 2021. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no
transport (A0998) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).

You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan follows Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months. 

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 RFA. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has had two sessions since January 2021 in the lumbar region. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular nerve stimulator (64555, L8679).

You asked the Plan to pre-approve an auricular nerve stimulator. You say that this is covered by Medicare. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that the service for auricular peripheral nerve stimulation will be denied as non-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 auricular nerve stimulator. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found an auricular percutaneous nerve stimulator is non-covered by Medicare when used for any indication. 

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 auricular nerve stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular nerve stimulator (64555, L8679).
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 you do not have daily skilled services.

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 were admitted to the acute hospital after a fall. You were treated for a urinary tract infection and pneumonia. You are medically stable and do not have any acute exacerbation of chronic medical problems. The most recent therapy documentation indicates you are able to ambulate up to 120 feet with a wheeled walker without hands on assistance. You can also accomplish transfers and bed mobility without hands on assistance. You do not require skilled nursing or skilled 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.