Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment (81404 and 81479)
provided on November 9, 2020.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all
cardiovascular risk assessment panels for patients with suspected or documented cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.

The test at issue in this appeal, the cardiovascular risk assessment, was requested solely for screening purposes.
Medicare does not cover this test solely for screening purposes. The documentation submitted does not include
any clinical information to determine why this testing was ordered or how it will affect the member's treatment.
Additionally, this testing has not been billed with the appropriate CPT codes for cardiovascular disease
screening. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment
(81404 and 81479) provided on November 9, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation that skilled nursing or therapy is required.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 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 visits. Our reviewer says that the requested visits is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that you require skilled nursing services or skilled rehabilitation services to provide treatment that is medically necessary. You do not require skilled nursing or rehabilitation services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The documentation indicates that you require custodial care including bathing and assisting while turning in bed. The requested home health services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health visits.
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 disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
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 medically necessary. Our physician reviewer found you were admitted to the hospital for lower extremity weakness and swelling (lymphedema). You are now medically stable with no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for am 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro orthosis (L8702).

You asked the Plan to pre-approve a MyoPro orthosis. You say that the requested item is a medical necessity
for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested item is experimental/investigational.

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 MyoPro orthosis. Our reviewer says
that the requested item is not considered medically reasonable and necessary in this case. Our physician
reviewer found that, based on scientific evidence, professional standards, and expert opinion, the MyoPro is not
known to be effective in improving health outcomes in stroke patients. The MyoPro is not in widespread use
based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve 
the long-term outcomes for the enrollee, improve hemiparetic arm function, or be safe for long term
use. There is insufficient evidence in the literature that this device will increase participation in bimanual
activities. There is insufficient literature in the peer-reviewed publications to assess safety, efficacy, long-term
outcomes or patient management associated with the use of the MyoPro orthosis for upper extremity
paralysis/paresis from conditions such as multiple sclerosis.

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 MyoPro orthosis have not been met. Therefore, we decided that the Plan does
not have to pre-approve a MyoPro orthosis (L8702).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist telehealth services provided by a participating provider on May 14, 2021.
You asked the Plan to waive the copayment for specialist telehealth services. You say that you only had a phone call, and not an office visit. 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 $50 copayment for physician/practitioner services/telehealth services/specialist virtual.
You have been asked to pay a $50 copayment for specialist telehealth services. Telehealth services are subject to the same cost sharing amount as in-person office visits; therefore, the correct copayment has been applied. Specialist telehealth services fall within the physician/practitioner services/telehealth services/specialist virtual 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 specialist telehealth services provided by a participating provider on May 14, 2021.
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 medical records provided support the need for an IRF level of care. The Plan denied your request. The Plan says the enrollee's condition is stable, and she does not require the requested 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 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 minimally invasive aortic valve replacement. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee and billed under
code 99223 from August 8, 2020, to August 10, 2020.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says the records provided do 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 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
this service. Our reviewer says that Medicare billing criteria are not met. Our reviewer found for CPT 99233 -
documentation does not support this level of service. To code for this level, 2 of 3 key components must be met
or exceeded. In this case, Expanded Problem Focused history was obtained. Two conditions = brief, 1 review
of systems (constitutional) Genitourinary = Pertinent to problem and no PFSH obtained.

The documentation shows a comprehensive exam with 9 organ systems reviewed. Medical decision making of
low complexity 2 presenting problems = limited, diagnostic procedures lab test reviewed = minimal, and
management options = moderate. Therefore, documentation does not support the level of CPT 99233.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not
have to pay for physician services provided to the enrollee and billed under code 99223 from August 8, 2020,
to August 10, 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 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 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 does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your needs can be 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluations.

Your care needs can be met at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on April 22, 2021.
You asked the Plan to pay for the prophylaxis and periodic oral evaluation. You say that the doctor was your dentist with your previous health insurance. You say that the bill should be reconsidered as you thought the dentist was listed. The Plan denied your request. The Plan says out-of-network dental services are not covered.
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, out-of-network dental services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the prophylaxis and periodic oral evaluation provided on April 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7210), the bone replacement graft (D7953),
and the unspecified preventive service (D1999) provided on April 22, 2021.
You asked the Plan to pay for the dental service. You say that this was for oral surgery. You say that the
services were not elective. You also say that the provider was in network. The Plan denied your request. The
Plan says the services you received are not listed as covered. The Plan says that you were advised of there is no
coverage for extractions and a breakdown of your plan benefits prior to the date of service. The Plan also says
that the claim processed correctly.
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 extraction, bone replacement graft,
and unspecified preventive service are not among those covered under this benefit. Therefore, we decided that
the Plan does not have to pay for the extraction (D7210), the bone replacement graft (D7953), and the
unspecified preventive service (D1999) provided on April 22, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve Aranesp. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 Aranesp. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 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 Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that your ongoing skilled therapy and nursing needs can be provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for osteomyelitis of the left foot.
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 IRF care is medically necessary. The Plan denied your request. The Plan says under Medicare, the request is not medically necessary.
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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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.