Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary for you to regain the strength and ability to work your daily routine. The Plan denied your request. The Plan says under Medicare, your 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.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5 occupational therapy visits, and 5 speech therapy visits.
You asked the Plan to pre-approve 5 occupational therapy visits and 5 speech therapy visits. You say that you need these services. The Plan denied your request. The Plan says the occupational and speech therapy services are not medically necessary.
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 5 occupational therapy visits and 5 speech therapy visits. Our reviewer says that 5 occupational therapy visits and 5 speech therapy visits are not medically necessary. Our physician reviewer found the provided documentation does not indicate that additional skilled occupational and speech therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. The reviewer found that the provided records do not document why the already provided occupational and speech therapy services have been inadequate to treat the enrollee's condition. Therefore, the reviewer found that the requested services 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 5 occupational therapy visits and 5 speech therapy visits have not been met. Specifically, the file shows that the requested home health services are not required to effectively provide treatment or in order to improve the enrollee's function. Therefore, we decided that the Plan does not have to pre-approve 5 occupational therapy visits, and 5 speech therapy visits.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a partial thyroidectomy.
You asked the Plan to pre-approve the partial thyroidectomy. You say that it is felt that this surgery is necessary based on the test results. The Plan denied your request. The Plan says that the fine needle aspiration biopsy showed that the nodule does not have malignant features, based on size and cytology. This means that removal is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the partial thyroidectomy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has a thyroid nodule that was found to have an American College of Radiology Thyroid Imaging Reporting & Data System (ACR TI-RADS) risk category of 5. There is a 35% risk of malignancy. Partial thyroidectomy is medically necessary and reasonable in this situation, as defined by Medicare rules. The elements of the coverage criteria are 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 partial thyroidectomy have been met. Therefore, we decided that the Plan has to pre-approve a partial thyroidectomy.
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 admission to an IRF provides the best outlook for
your safe and speedy recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF
are not met. You can safely receive the services you need in a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, there is no documented need for
an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy evaluation provided by an
occupational therapist on August 11, 2020.
You asked the Plan to pay for the occupational therapy evaluation. You say that the medical records required to
reprocess the denied claim are attached. The Plan denied your request. The Plan says the code is not
appropriate for the service billed.
The Plan must follow Medicare rules. Medicare rules say that services of an occupational therapist billed as
services incident to a physician/non-physician practitioner's service must meet all incident requirements.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the occupational therapy evaluation have not been met. Specifically, the billing provider is a nurse
practitioner. As such, occupational therapy services cannot be paid incident to this provider's professional
services. Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation
provided by an occupational therapist on August 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a neurologist on May 1, 2021.
You asked the Plan to waive the copayment for the neurology visit. You say that you were in the hospital at this time, so you should not have a copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan states that you were in observation care from the emergency room from April 30, 2021, to May 1, 2021. You were not an inpatient. The Plan says that you have additional cost sharing for some services in the emergency room.
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 $15 copayment per visit or consultation in an outpatient location with a specialist. You have been asked to pay a $15 copayment for the neurology visit. Your Evidence of Coverage states that you may have to pay additional copayments for services you get from certain providers in the emergency room. In this case, it appears you were in observation in the emergency room when you had the consultation with this neurologist. Both the emergency room and observation are outpatient locations. The Evidence of Coverage states that you pay a $15 copayment for consults in an outpatient location with a specialist. 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 the visit you had with a neurologist on May 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic facet joint injections (64494, 64493).
You asked the Plan to pay for therapeutic facet joint injections. You say that although the enrollee is a candidate for radiofrequency ablation, she requires a therapeutic procedure. The Plan denied your request. The Plan says the requirements for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary only if there is documentation of why the patient is not a candidate for radiofrequency ablation (such as established spinal pseudarthrosis, implanted electrical device) is in the medical record. We looked at the file and Medicare rules. The submitted records do not include documentation of why the
enrollee is not a candidate for radiofrequency ablation. Based on this information, we decided that Medicare rules for coverage of therapeutic facet joint injections have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic facet joint injections (64494, 64493).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 10, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee is not yet safe to go home. They are sleeping very little and are undergoing medication changes at this time. The Plan denied your request. The Plan says as of November 10, 2021, the enrollee no longer meets the criteria for inpatient psychiatric care and can be moved to a less restrictive setting.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued inpatient psychiatric care. Our reviewer says that the health plan's denial of continued inpatient psychiatric care appears appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient psychiatric hospitalization on October 10, 2021 with Schizoaffective Disorder Depressed Type. Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time beyond the dates in question as he was not showing any dangerousness to self or others, auditory or visual hallucinations and was without aggressive behaviors while not showing any acute threats of safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as he did not have any suicidal or homicidal thoughts, auditory or visual hallucinations or abnormal behaviors. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of November 10, 2021, forward and could have been treated in a lesser restrictive setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care from November 10, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure device or CPAP
(E0601, E0562).
You asked the Plan to pre-approve the CPAP. You say that the claim should be paid. The Plan denied your
request. The Plan says the enrollee has previously received the same supplies within the 5-year RUL.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical
equipment is no less than five years. Replacement equipment may be granted when irreparable wear or
irreparable damage is demonstrated or there has been a change in the enrollee's medical condition.
We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that the
enrollee has received the same durable medical equipment in 2020. There is no evidence that this CPAP and
Humidifier is damaged, broken, or malfunctioning beyond repair. Based on this information, we decided that
Medicare rules for coverage of the CPAP have not been met. Therefore, we decided that the Plan does not have
to pre-approve a continuous positive airway pressure device or CPAP (E0601, E0562).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
You asked the Plan to pre-approve the home ventilator. You say that the enrollee has chronic respiratory failure. You state this is a steady state for the enrollee and there is elevation of their serum bicarbonate. You state mechanical ventilation for noninvasive support will decrease the enrollee's work of breathing, improve their pulmonary status, prolong the enrollee's life and may decrease admission to the hospital. The Plan denied your request. The Plan says a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has severe chronic obstructive pulmonary disease (COPD) with carbon dioxide (CO2) retention documented on arterial blood gases (ABG) done while stable. The enrollee may benefit from BiPAP support during sleep. Certain BiPAP devices can provide the AVAPS mode of support, and Medicare does not cover a home ventilator when used as BiPAP. The denial is upheld. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81001, 87086, 87088, 87186) rendered by the out-of-network (OON) provider on May 14, 2021.
You asked the Plan to pay 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 services were rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the laboratory services (81001, 87086, 87088, 87186) rendered by the out-of-network (OON) 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 you need IRF care in order to be able to recover fully. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. Your ongoing skilled therapy needs are being met in your current facility.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit provided on May 24, 2021.

You asked the Plan to pay for the office visit. You say that the enrollee was seen for a new diagnosis. The Plan denied your request. The Plan says that the provider was seen previously within the same group practice.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

In this case, the CPT Code Manual definition of code 99204 is office visit for the evaluation and management of a new patient. We find that CPT code 99204 is supported in the medical record. The records show that the enrollee was previously seen by a vascular surgeon. On the date of service at issue, the enrollee received care from a surgical oncologist. Although part of the same medical group, the enrollee was seen by providers from different specialties. Based on this information, we decided that Medicare rules for coverage of the office visit have been met. Therefore, we decided that the Plan has to pay for the office visit provided on May 24, 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 the outpatient office visit (99203) provided September 29, 2020 to December 18, 2020
You asked the Plan to pay for the office visit. You say that you are contesting the nonpayment of the claim You were told that your codes were correct and to resubmit all claims again. The Plan denied your request. The Plan says this service is not covered when rendered 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 pay for the outpatient office visit (99203) provided September 29, 2020 to December 18, 2020