Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the prosthetic leg components (CPT code(s) L5400, L5450, L8420 and L5688).
You asked the Plan to pre-approve the prosthetic leg components. You say that you underwent right below knee amputation (BKA) on September 22, 2021, due to failed wound healing. You state Immediate Post-Operative Prosthesis (IPOP) was provided during hospital stay. The Plan denied your request. The Plan says an IPOP is included with coverage for hospital stay and cannot be requested separately. 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 prosthetic leg components have not been met. Payment of prosthesis received during hospital stay is already included with the payment to the hospital. This cannot be covered separately. Therefore, we decided that the Plan does not have to pre-approve the prosthetic leg components (CPT code(s) L5400, L5450, L8420 and L5688).
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 IRF services are medically necessary. The Plan denied your request. The Plan says 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 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. 

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 care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is needed to work on the enrollee's ambulation, steps training, transfer, increase standing tolerance, and balance for a safe discharge home. The Plan denied your request. The Plan says medical necessity rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee does not require skilled nursing services with the specialized skill, knowledge, and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF beyond the last covered date. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing 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 does not require the necessary services on an inpatient basis in a skilled nursing facility setting beyond the last covered date. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous device placement (22867, 63047,
63030).

You asked the Plan to pre-approve the interspinous device placement procedure. You say that the procedure is
medically necessary. The Plan denied your request. The Plan says this procedure is investigational and is not
covered.

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 revie
wer 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 interspinous device placement
procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary
in this case. Our physician reviewer found the Coflex device is experimental. More research is needed to show
safety and efficacy of the device. High failure rates have been reported with similar devices.

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 interspinous device placement procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous device placement (22867, 63047, 63030).
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. You say that the enrollee will continue to require the skills of
nurses and physical therapy for ongoing assessment. The Plan denied your request. The Plan says the enrollee
has no skilled nursing or acute skilled therapy needs. 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 the enrollee was admitted to the acute hospital due to confusion. She was diagnosed with a complete
heart block. She underwent placement of a cardiac pacemaker and has stabilized medically. She does not have
any acute exacerbation of chronic medical problems. Although further rehab services would be appropriate to
improve function, she 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide (HHA) services (S9122).

You asked the Plan to pre-approve the HHA services. The Plan denied your request. The Plan says you do not meet the criteria established by the Centers for Medicare and Medicaid Services (CMS).

The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or 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 HHA services. Our reviewer says that the requested home health services are not medically 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. Our reviewer found that you do not require skilled nursing or rehab 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. Our physician reviewer also found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

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 HHA services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health aide (HHA) services (S9122).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a percutaneous implantation of neurostimulator electrode
array (63650) provided on June 11, 2021.
You asked the Plan to pay for a neurostimulator placement. You say that the procedure at issue was a medical
necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the
procedure at issue have not been met.
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless all of the
conditions listed in the Medicare rules section of this letter have been met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for a neurostimulator placement. Our reviewer
says that the procedure at issue was not medically reasonable and necessary in this case. Our physician
reviewer found that the documentation does not support that the enrollee had chronic intractable pain for which
other treatment modalities (pharmacological, surgical, physical, or psychological therapies) had been tried and
did not prove satisfactory or were judged to be unsuitable or contraindicated.
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 neurostimulator placement have not been met. Therefore, we decided that the
Plan does not have to pay for a percutaneous implantation of neurostimulator electrode array (63650) provided
on June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission for a surgical procedure.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient stay is medically necessary. The Plan denied your request. The Plan says the procedure can safely be performed in the outpatient setting.

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 care are met in this case. Our physician reviewer found the enrollee is undergoing a planned elective total Right reverse shoulder arthroplasty. She is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure is listed under CPT code 23472 which is NOT listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.

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 an inpatient hospital admission for a surgical procedure.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ambulance transportation (A0428).

You asked the Plan to pre-approve the ambulance transportation. You say that the ambulance services are
medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 ambulance transportation. Our
reviewer says that the ambulance services are not medically necessary. Our physician reviewer found the
record shows previous ambulance transport to and from dialysis. The records do not show any reason other
means of transportation would be contraindicated.

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 ambulance transportation have not been met. Therefore, we decided that the
Plan does not have to pre-approve ambulance transportation (A0428).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary.

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 enrollee appears to be stabilizing and improving but requires additional shortterm
acute care services that can be safely be completed at the current acute care facility. The enrollee does not
require services at the LTACH that are not already available at the current facility. There are no services at the
LTACH that the enrollee requires that are not already available and covered at the current facility. The LTACH
services will be considered not medically necessary as transfer would not provide any significant change in
treatment. Transfer to a lower level of care may be considered when treatment, including weaning, has
completed.

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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).
You asked the Plan to pre-approve a power scooter. You say that you need this to go to the store. The Plan denied your request. The Plan says this is not covered for use outside the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT code(s): 64493 and 64494).

You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied your request. The Plan says your request is not medically necessary because your records show you did not have at least 80% relief of pain after the first diagnostic facet joint procedure.

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 injections. Our physician reviewer found the records do not show that you had adequate pain relief with previous injection therapy. More documentation is needed. 

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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injections of lower or sacral spine facet joint using imaging guidance (CPT code(s): 64493 and 64494).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a urology office visit to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a urology office visit. You say that the requested provider is the only provided in the area that can do the treatment the enrollee needs. The Plan denied your request. The Plan says this is available 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 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 a urology office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics (L3040) provided on April 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for foot orthotics. You say that these items help you balance and get around. The Plan denied your request. The Plan says these items were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. 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 foot orthotics (L3040) provided on April 27, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services (23650) provided on January 27, 2021.
You asked the Plan to pay for the services. You say that fasfdsa The Plan denied your request. The Plan says that this service was performed on a different date of service.
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 the services. Our reviewer says that the use of code 23650 is supported by the records provided. Our reviewer found that no documentation was found to support any billing outside of January 27, 2021. The emergency room visit documents the billed date of service. Therefore, the billed code is supported. 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 been met. Therefore, we decided that the Plan has to pay for the services (23650) provided on January 27, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for moderate sedation services (procedure code 99153) provided to the enrollee on April 16, 2021.
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 place of service was inappropriate for this procedure.
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 99153 is "Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)." 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 21 - Inpatient Hospital. This code is inappropriate for a physician to bill. This service is performed by a nurse or independent trained observer, and would be billed by the facility. 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 moderate sedation services (procedure code 99153) provided to the enrollee on April 16, 2021.