Persius/hicric huggingface dataset:
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 a LTACH transfer is medically necessary. The Plan denied your request. The Plan says these services can be provided on an inpatient basis.
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 is receiving appropriate care at the present acute care facility. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the hip for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says imaging is covered when all standards are met for treatment.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the hip. The provided records do not indicate the medical necessity or reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of the hip for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON physical therapy services. You say that physical therapy is medically necessary. You say that the requested provider is the most convenient location for the frequency of visits that are required due to the severity of your back pain and dysfunction. The Plan denied your request. The Plan says no medical need was shown as to why the enrollee cannot get physical therapy from a network provider.
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 physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the enrollee has failed greater than twelve (12) months of conservative approaches to treatment at this time. You state failed conservative treatment approaches include restricted activity, pain medication, and epidural steroid injections. The Plan states this enrollee is still experiencing significant loss in ability to complete normal daily activities due to their lumbar stenosis as is reflected on the enrollee's radiographic imaging. The Plan denied your request. The Plan says medical studies have not proven that the device(s) is helpful for treatment of the enrollee's health problem.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee indicates that the enrollee has chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that the enrollee has had minimally invasive lumbar discectomy at L3-L4 and L4-l5, the levels requested for treatment. The record indicates that imaging shows multi-level disease including moderate to severe spinal stenosis at both recommended treatment levels. The
record does not indicate that the enrollee is not indicated for operative treatment at more than two levels. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of at least three insulin injections per day, or use of an insulin pump.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested monitor is not medically reasonable or necessary. Our physician reviewer found the enrollee does not take three or more shots of insulin per day.
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 monitor have not been met. Therefore, we decided that the Plan does not
have to pre-approve a continuous glucose monitor for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the heart rhythm tracing to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the heart rhythm tracing. You say that you were unaware the provider is out-of-network. You say your doctor suggested the provider himself. The Plan denied your request. The Plan says the provider is out-of-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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the heart rhythm tracing to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 16, 2019 to September 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the submitted records do not support the billing of primary diagnosis D62 and secondary diagnosis M72.6.
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 provided with primary diagnosis D62 (acute posthemorrhagic anemia) and secondary diagnosis M72.6 (necrotizing fasciitis). 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 these services. Our reviewer says that the submitted records do not support the billing of primary diagnosis D62 and secondary diagnosis M72.6. Our physician reviewer found the enrollee was admitted to outpatient same-day surgery on September 16, 2019 at 8:40 AM and admitted to inpatient status on the same date at 5:45 PM with notes that state "she was admitted with a hemoglobin of 7.5 and transfused." The discharge summary hospital course narrative states, "was initially seen in the ambulatory care with necrotizing left forearm infection that was debrided, following that procedure the patient had to be admitted because of a drop in hemoglobin likely acute blood loss from trauma-related abdominal wall hematoma, she was transfused 2 units of packed red blood cells uneventfully." In this case, the documentation indicates that the patient was admitted after outpatient surgery for another condition unrelated to the surgery and therefore the enrollee's unrelated condition of acute blood loss anemia is assigned as the principal diagnosis. The records do not support the billing of primary diagnosis D62 (acute posthemorrhagic anemia) and secondary diagnosis M72.6 (necrotizing fasciitis). 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 rendered from September 16, 2019 to September 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on April 22, 2021, through May 15, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the cost share is wrong. The Plan denied your request. The Plan says the cost share was applied correctly.
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 $450 copayment each day one through four for inpatient hospital care. You have been asked to pay a $450 copayment each day one through four for the inpatient hospital care. the inpatient hospital care falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on April 22, 2021, through May 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fusion of additional bones in spine, bone graft from
donor, and posterior segmental instrumentation (CPT code(s): 22614, 20930, and 22842), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the lumbar fusion at L5-S1 is approved. The Plan state this level has documented
isthmic spondylolisthesis. The Plan states there are no other levels of documented instability or deformity so
the addition of two additional levels of posterior fusion cannot be approved at this time. The Plan states a
request for bone graft materials and/or substitutes, CPT 20930, must include the name of the product. The Plan
states in the absence of that information, the request is considered incomplete and cannot be processed.
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 services. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found L5-S1 fusion should be approved. Fusion is not needed at other levels due to lack of instability,
fracture, or lesion. 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 pre-approve fusion of additional bones in spine, bone graft from donor,
and posterior segmental instrumentation (CPT code(s): 22614, 20930, and 22842), for the enrollee
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from November 5, 2021, forward.
You asked the Plan to pre-approve SNF care. You say that you are a danger to yourself and it would be life threatening to be released. You state you are not healthy enough to go home. You state your care was not adequate enough. 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 there is no documentation that you require skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide medically necessary and reasonable treatment. You do require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified therapist are required to safely and effectively provide medically necessary and reasonable treatment. Daily skilled services are not required. You do not require the services on an inpatient basis, only in a SNF setting. Services in the home with home health care or in a long-term care facility on a part time basis appear appropriate in this case. 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 November 5, 2021, forward
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on November 29, 2020.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 29, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says a review of the current medical literature indicates that this service is considered experimental and investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT (CPT code 77525), for the enrollee.
You asked the Plan to pre-approve the PBRT. You say that the services are medically necessary to treat module with protons without hitting the heart. The Plan denied your request. The Plan says the request is considered not medically reasonable and necessary, as this service is considered experimental and investigational for the palliative treatment of lung cancer, and there is no indication of the enrollee's enrollment in a Medicare approved clinical trial. The Plan states there are other radiation therapies available to the enrollee which are medically appropriate.
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 PBRT. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that proton therapy is needed over other accepted treatments. There is no plausible reason that proton therapy would be more beneficial than standard therapy for this particular enrollee. 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 PBRT have not been met. Therefore, we decided that the Plan does not have to pre-approve the PBRT (CPT code 77525), for the enrollee.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the lab services provided April 16, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the lab services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says that this provider must be contracted with Medicare in order to receive payment for services rendered.
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. In this case, there is no evidence that the provider is not contracted with Medicare. It is the burden of the Plan to provide proof to substantiate their denial. Therefore, we decided that the Plan has to pay for the lab services provided April 16, 2021, by an out-of-network (OON) provider.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve non-standard size or width (CPT code L3254) and orthopedic footwear, mens shoe, depth inlay, each (CPT code L3221).
You asked the Plan to pre-approve foot orthotics. You say that you have feet pain all of the time, and difficulty wearing any shoes as a result. You state your feet are deformed due to Charcot-Marie-Tooth (CMT) disease, a neurological condition, that has been worsening. The Plan denied your request. The Plan says Medicare does cover foot inserts and custom molded shoes for individuals with diabetes who have nerve damage to their feet, and also have calluses and/or ulcers. The Plan states these inserts and shoes have a different supply code (A5512-A5514) than the one your doctor requested.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. These inserts and shoes have a different supply code (A5512-A5514) than the one your doctor requested. L3254 and L3221 are not approved for coverage because they are not covered for what you need them for. Therefore, we decided that the Plan does not have to pre-approve non-standard size or width (CPT code L3254) and orthopedic footwear, mens shoe, depth inlay, each (CPT code L3221).