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

We decided that the Plan does not have to pay for the inpatient hospital services provided from November 2, 2020, to November 9, 2020.
You asked the Plan to pay for the services provided. You say that hyponatremia was diagnosed, monitored, and treated. The Plan denied your request. The Plan says clinical validation of the diagnosis was not supported in the medical records.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services with diagnosis code E87.1 defined as hypoosmolality and hyponatremia. 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 the services provided. Our physician reviewer found that the enrollee presented to the hospital with vertebral fracture related to osteoporosis. Kyphoplasty was performed. Hypoosmolality and hyponatremia, E87.1, was listed as a secondary diagnosis for the admission. On admission sodium was 132 mmol/L and repeated ranged from 131-137 during the hospital stay. There was no report of altered mental status or other signs of clinical hyponatremia. The documentation did not describe treatment for clinically significant hyponatremia, namely fluid restriction, concentrated saline administration, or follow up testing such as urine osmolality. Only monitoring was noted as the treatment for this diagnosis. Therefore, the documentation does not sufficiently and consistently support that this secondary diagnosis was treated at this hospital stay. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from November 2, 2020, to November 9, 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 it is felt that IRF care is necessary to increase the enrollee's function. The Plan denied your request. The Plan says the criteria for IRF care are not met in this case.
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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for peritonitis and surgical repair of perforated colon complicated by respiratory failure and COVID-19 pneumonia. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. While the patient 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an occlusal guard.
You asked the Plan to pre-approve an occlusal guard. You say that your pain has not subsided. The Plan denied
your request. The Plan says that this is not a covered benefit.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an
occlusal guard.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the panoramic radiographic image
(D0330) provided October 13, 2021.
You asked the Plan to provide additional payment for the panoramic x-ray. You say that you were told the
services would be covered. The Plan denied your request. The Plan says the costs above your dental allowance
is your responsibility.
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. The Plan covers the panoramic
x-ray up to the $1,500 maximum dental allowance amount.
We looked at the file and Medicare rules. The Plan provided documentation showing that this service was
covered up to your dental allowance amount. The remaining costs over this amount are your responsibility.
Therefore, we decided that the Plan does not have to provide additional payment for the panoramic
radiographic image (D0330) provided October 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic CGM and supplies, for the enrollee.
You asked the Plan to pre-approve the items. You say that the items are necessary The Plan denied your request. The Plan says the items are not covered.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. Review of the file shows the enrollee does not take insulin or adjust an insulin dose based on their blood glucose results. The enrollee intends to use a CGM for monitoring, not therapeutic reasons. Based on this information, we decided that Medicare rules for coverage of the items have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic CGM and supplies, for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second set of cervical epidural steroid injections (ESIs).
You asked the Plan to pre-approve ESIs. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the Plan approved 1 unit of epidural steroid injections and no more than 2 level of a spine area can be done during a single setting.
The Plan follows Medicare rules. Medicare rules state that epidural steroid injections may be covered under certain conditions. 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 ESIs. Our reviewer says that the enrollee does not meet the Medicare criteria for a second ESI. Our physician reviewer found there is no role for a series of epidural steroid injections. Each injection needs to be evaluated for efficacy and duration before another injection is approved. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ESIs have not been met. Therefore, we decided that the Plan does not have to pre-approve a second set of cervical epidural steroid injections (ESIs).
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 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 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 the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. The enrollee is medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. The enrollee does not have any parental medication; complex wound care or nutrition given via a feeding tube. The enrollee is medically stable without any acute exacerbations of chronic medical problems. The enrollee's physical function is at or near their baseline and they can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair, group 2 standard, captains chair,
patient weight capacity up to and including 300 pounds (CPT code K0823), for the enrollee.
You asked the Plan to pre-approve the DME. You say that the enrollee is unsteady and has mobility issues due
to diagnosis of multiple sclerosis. You state the enrollee is unable to use a standard wheelchair due to their
medical issue. The Plan denied your request. The Plan says your request is not medically necessary because the
enrollee's records do not show documentation as to the enrollee's ability to safely maneuver a power wheelchair
or their caregiver's inability to push the enrollee in a manual wheelchair, nor documentation of an assessment
of the enrollee's home's ability to accommodate a power wheelchair, nor documentation that the enrollee or
their caregivers can safely transfer the enrollee into and out of a power wheelchair.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.
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 DME. Our physician reviewer
found the documentation states that the enrollee has a mobility deficit, but the documentation is not specific on
what mobility-related activities of daily living (MRADLs) in the home are impaired or why this mobility
limitation is not ameliorated by a walker, cane, manual wheelchair. The enrollee is noted to have no upper
extremity range of motion (ROM) or strength limitations on the referral. There is no detailed objective
physician evaluation of gait, ROM, strength of the upper and lower extremities. There is not a detailed home
assessment to support that the requested device will be able to safely maneuver in the home and access rooms
for MRADL participation. The documentation does not support that the Group 2 power wheelchair will
significantly improve the enrollee's ability to participate in MRADLs and the enrollee will use it in the home.
The documentation does not reveal that the requested K0823 is medically necessary per LCD L3378 and NCD.
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 DME have not been met. Therefore, we decided that the Plan does not have
to pre-approve the power wheelchair, group 2 standard, captains chair, patient weight capacity up to and
including 300 pounds (CPT code K0823), for the enrollee.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 has had a prolonged hospital course with hypotension and concerns of
ongoing hemothorax and requires ongoing acute care services. The medical record does not indicate that the
enrollee requires services that he is not currently receiving but that would be available at the LTACH 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspirate procedure (20939).

You asked the Plan to pre-approve the bone marrow aspirate procedure. You say that the procedure is medically necessary. The Plan denied your request. The Plan says this service is investigational and is non-covered at this time.

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 bone marrow aspirate procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate is still considered experimental. More research is needed to show safety and efficacy of this procedure. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the bone marrow aspirate procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a bone marrow aspirate procedure (20939).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (98943, 97140, G0283,
and A4556) provided on August 4, 2021.
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says codes 98943, 97140, G0283,
and A4556 are not covered when billed 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 services at issue, codes 98943, 97140, G0283, and A4556 are not manual
manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered
chiropractic services (98943, 97140, G0283, and A4556) provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (CPT code 97802) provided to the enrollee on December 18, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not 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 the services. Our physician reviewer found the enrollee does not meet NCD criteria for MNT at this time. Also, there was no failed treatment from the physician's advice which was already quality advice to reduce gastritis symptoms. Additional nutrition therapy would likely not have been more helpful. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (CPT code 97802) provided to the enrollee on December 18, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus Ointment for the enrollee.
You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan
denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus Ointment for
the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right total knee arthroplasty.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that records show you have not pursued a full course of supervised
physical therapy for your condition and also show you do not have severe bone-on-bone arthritis by imaging
studies.

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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Severe right knee
osteoarthritis is not clearly demonstrated on the imaging studies provided for review. Additionally, detailed
documentation is not evident regarding trial and failure of a recent course of physical therapy for the right knee.
Significant impairments in your quality of life are not evident on exams provided for review. There are limited
large-scale, long-term references showing the safety and efficacy of the requested surgery in this clinical
setting of non-severe osteoarthritis on imaging, no physical therapy documented to have tried/failed, as well as
no clear documentation of significant impairments. Our physician reviewer found that your condition does not
meet criteria for these services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a right total knee arthroplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from January 24, 2022, forward.
You asked the Plan to pre-approve SNF care. You say that you still need more physical therapy in the SNF setting. You state you were unable to participate in physical therapy due to pain and infection for the first several days in the SNF. You state that it was later found that you had a urinary tract infection as well as kidney stone. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you no longer require daily skilled services and the continuation of SNF is not medically necessary.
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 you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear to have reached a plateau in function. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from January 24, 2022, forward