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

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from April 1, 2020, to April 13, 2020. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider has reported skilled services with the incorrect PDPM Health Insurance Prospective 
Payment System (HIPPS) Score. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The provider billed a PDPM score of KDXF1, which requires support a nursing function score of 10 and 
PT/OT function score of 14. 
 
We find that these scores are not supported, as there are certain items that are not specifically noted in the 
records. In terms of therapy score, the evaluations only use broad terms, such as "toileting" or 
"hygiene/grooming" without giving specifics on the enrollee's functional level for these activities. When this 
happens, the default score must be used, rather than the higher score used by the provider. 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 skilled nursing facility (SNF) services provided to the enrollee 
from April 1, 2020, to April 13, 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 need the rehabilitation for your leg because you
are not able to walk or go up the stairs. The Plan denied your request. The Plan says authorization denied
because the IRF care is not medically necessary, and your needs can be met at a lower level of care such as a
skilled nursing facility (SNF).
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 your medical problems are stable, and 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 you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
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 issue additional reimbursement for the periodic oral evaluation (D0120), the dental cleaning (D1110), the intraoral-complete series of radiographic images (D0210) and the onlay-porcelain/ceramic-four or more surfaces (D2644) provided on August 24, 2021 and September 1, 2021.
You asked the Plan to issue additional reimbursement 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 claim for these services has been 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. 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for additional reimbursement for these services have not been met. Specifically, the intraoral radiographic images and the dental onlay provided are not covered benefits under your contractual policy. Additionally, the oral evaluation and the dental cleaning provided were reimbursed to you by the Plan at the maximum allowable rate; therefore, you will be liable for the balance of these services. The Plan contract states that you may be billed by an out-of-network provider for any amount greater than the payment made by the Plan. Therefore, we decided that the Plan does not have to issue additional reimbursement for the periodic oral evaluation (D0120), the dental cleaning (D1110), the intraoral-complete series of radiographic images (D0210) and the onlay-porcelain/ceramic-four or more surfaces (D2644) provided on August 24, 2021 and September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee currently meets LTACH
admission under CMS guidelines. The Plan denied your request. The Plan says authorization denied because
the LTACH is not medically necessary, and the enrollee's needs can be met at a lower level of care, such as a
skilled nursing facility (SNF).
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The health plan has approved ongoing care
in the current acute care facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 additional PT visits. You say that the requested additional visits are medically necessary. The Plan denied your request. The Plan says additional PT visits are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 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 the provided records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy and occupational therapy, by or under the supervision of a therapist. Therefore, the reviewer found that the additional visits are 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve unlisted molecular pathology (CPT code 81479).
You asked the Plan to pre-approve the laboratory services. You say that the services are necessary. The Plan denied your request. The Plan says the submitted documentation does not support the approval, and this sort of genetic testing for generalized anxiety disorders is not recommended by the CPIC or the FDA. The Plan states that they need the following: One, the medication(s) being used to treat the patient or that are being considered for treatment. Two, the list of health problems that treatment is being used for.
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 laboratory services. Our physician reviewer found the reviewed documentation indicates that provider did send in medical records including a medication list, and a diagnosis report stating the enrollee has a psychotic disorder with delusions, as well as major depressive disorder. The submitted documentation does not support the approval, and this sort of genetic testing for generalized anxiety disorders is not recommended by the CPIC or the FDA. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 
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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pre-approve unlisted molecular pathology (CPT code 81479).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says you are receiving appropriate inpatient acute care and do not require transfer to a LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. Our reviewer also found that 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the wheelchair. 
 
You asked the Plan to pre-approve the wheelchair. You say that you have a scooter, but it is too big, and you 
live in a mobile home and need a wheelchair for inside the house and to and from any cars. The Plan denied 
your request. The Plan says they were not provided with a physicians order and the necessary medical 
information needed to support your request. The Plan states they must have a physicians order and the 
necessary medical information to provide you with an authorization for the wheelchair that you have requested. 
 
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 wheelchair have not been met. A physicians order and the 
necessary medical information was not provided to support your request. Therefore, we decided that the Plan 
does not have to pre-approve the wheelchair.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve repairs to the enrollee's wheelchair. 
 
You asked the Plan to pre-approve the repairs. You say that the services are necessary. The Plan denied your 
request. The Plan says that the enrollee's records show that they will use the wheelchair in a nursing home (also 
called a skilled nursing facility (SNF)). The Plan states Medicare criteria do not cover the request. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The plan has not substantiated their denial as the records clearly show that the 
enrollee has been discharged from the SNF since August 8, 2020. Therefore, we decided that the Plan has to 
pre-approve repairs to the enrollee's wheelchair.  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service January 8, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service January 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare billing regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on September 26, 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 enrollee meets every level of criteria and the IRF care is reasonable and appropriate for the enrollee. The Plan denied your request. The Plan says authorization denied because the IRF care is not medically necessary, and the enrollee's needs can be met at a lower level of care such as a skilled nursing facility (SNF).
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 medical problems are stable, and 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a repeat epidural steroid injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says repeat injection is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the criteria for a repeat right L4-5, L5-S1 transforaminal epidural steroid injection have not been met. The documentation does not reveal that the patient has had at least 50% of sustained improvement in pain relief and/or improvement in function measured from baseline using the same scale for at least three months. 
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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a repeat epidural steroid injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies (A4520).
You asked the Plan to pre-approve incontinence supplies. You say that you are on a fixed income and the
requested items are expensive. The Plan denied your request. The Plan says the requested items are not a
covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered
because they are hygienic items that are non-reusable.
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies (A4520).
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 had excellent results when you received IRF 
care in the past. You say you need the IRF care to be safe. The Plan denied your request. The Plan says 
authorization denied because the IRF care is not medically necessary, and your needs can be met at a lower 
level of care such as a skilled nursing facility (SNF). 
 
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 your medical problems are stable, and 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 you have a need for physical 
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 
 
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 the foot insert (CPT code L3000). 
 
You asked the Plan to pre-approve the foot insert. You say that you have abnormally high arches as the request 
denial indicates, but all you wanted was to get diabetic shoes and inserts because you are diabetic. The Plan 
denied your request. The Plan says Medicare only covers these items if they are on a shoe that is an integral 
part of a covered brace and if they are medically necessary for the proper functioning of the brace. The Plan 
states this custom shoe insert is not part of a brace. 
 
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 foot insert have not been met. You wish to have diabetic 
shoes. Medicare rules (LCD A52481 for orthopedic footwear policy article) note that shoes, inserts and 
modifications are covered in limited circumstances. They are covered in selected beneficiaries with diabetes for 
the prevention of treatment of diabetic foot ulcers. However different codes (A5500 to A5514) are used for 
footwear provided under this benefit (therapeutic shoes for persons with diabetes). This was not the code that 
was entered in the request for you. The request was for an insert or shoe modification (L3000) which is not a 
diabetic shoe (A5500 to A5514). And Medicare rules only cover shoe inserts (L3000) if they are part of a shoe 
attached to a covered brace and are medically necessary for the proper functioning of the brace. Therefore, we 
decided that the Plan does not have to pre-approve the foot insert (CPT code L3000).