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 these services are medically necessary. The Plan denied your request. The Plan says that your nursing, medical management and rehabilitation needs do not require an interdisciplinary team approach to delivery of rehabilitation 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. The
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for an ankle fracture and were discharged home on September 16, 2021 when skilled nursing refused admission because of a positive coronavirus screen. You have ongoing weakness at home. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Plan has to pay for a focal laser ablation and MRI scans of the pelvis. We decided that the
Plan does not have to pay for a focal laser ablation.

You asked the Plan to pay for a focal laser ablation and MRI scans of the pelvis. You say that the services at
issue were a medical necessity for you. The Plan says that rules for payment have not been met because the
requested services are experimental/investigational.

We decided that the Plan has to pay for MRI scans of the pelvis.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 pay for MRI scans of the pelvis. Our reviewer says
that MRI scans at issue in this case are medically reasonable and necessary. Our physician reviewer found that
MRI of the prostate is the standard of care for needle biopsy guidance in patients with suspected prostate
cancer and for staging of newly diagnosed prostate cancer.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of MRI scans of the pelvis have been met. Therefore, we decided that the Plan has
to pay for MRI scans of the pelvis (72195, 72196) provided on January 19, 2021.

We also decided that the Plan does not have to pay for a focal laser ablation.

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 pay for a focal laser ablation. Our reviewer says that
a focal laser ablation procedure is not considered medically reasonable and necessary in this case. Our
physician reviewer found that Focal Laser Ablation is approved by the Food and Drug Administration (FDA)
for soft tissue ablation but has never been officially studied for treating prostate cancer. The procedure at issue
is considered experimental or investigational for your indication.

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 focal laser ablation have not been met. Therefore, we decided that the Plan
does not have to pay for a focal laser ablation (55899) provided on January 19, 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: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for an upper partial denture (D5213) provided on April 9, 2021.

You asked the Plan to pay for an upper partial denture. You say that you disagree with the Plan's denial. The
Plan denied your request. The Plan says that the service denied due to it exceeding the quantity or amount of
services allowable and/or covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of an upper partial denture have been met. Specifically, the Plan did not provide evidence that you
have exhausted this benefit. Therefore, we decided that the Plan has to pay for an upper partial denture (D5213)
provided on April 9, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on
January 11, 2021.
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 there is no valid physician order.
The Plan must follow Medicare rules. The rules say that a supplier must have an order from the treating
physician before dispensing any durable medical equipment (DME) item to a beneficiary.
We looked at the file and Medicare rules. There is no valid physician order for the DME. 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 pay for the continuous glucose monitor (CGM) supplies rendered on
January 11, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMs procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that there is no definitive evidence that the monitor, compared to conventional medical management and clinical monitoring, has been established as standard of care.
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 these services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. The patient has NYHA Class III heart failure with preserved ejection fraction and is on a high dose oral diuretic regimen with recurrent and hospitalization for congestive heart failure (CHF) in the past year. Management of her heart failure with standard medical therapy and relying on symptoms, weights and signs has not been effective in keeping her with minimal symptoms and has resulted in acute hospitalizations. Cardiomems device monitoring in this situation can provide additional heart filling pressure data to better manage very complex regimens to optimize fluid status. Data from the Champions trial along with longer term follow-ups studies have shown a significant decrease in hospitalizations and improvement in heart failure symptoms and NYHA Class with the use of this device. There is also published expert opinion in the cardiology literature as to its appropriate use as well as reasonable patient selection criteria, and FDA approved indications all of which are met in this clinical instance. Given the ongoing symptoms of recurrent CHF which appear very sensitive to volume loading conditions, the complexity of the medical regimen and the failure to prevent acute CHF hospitalization in this patient, use of the Cardiomems device is reasonable and has clinical data, expert opinion, and approved Food and Drug Administration indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational for this indication. Our physician reviewer found that the enrollee's condition meets criteria for coverage of 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 been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMs procedure for the enrollee.
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 pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network orthopedic specialist.
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 specialist services to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) provided on September 25, 2020.
You asked the Plan to pay for the non-emergency ambulance transport. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility for a scheduled appointment is not a Medicare covered benefit.
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 pay for the non-emergency ambulance transport. Our reviewer says that the ambulance transport on September 25, 2020 was not medically reasonable and necessary for the enrollee for this non-emergent physician office appointment. Our physician reviewer found the documentation does not support that other means of transport (such as stretcher van) were contraindicated for this enrollee on September 25, 2020. Our reviewer also found that the documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport.
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 non-emergency ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergency ambulance transport (A0428) provided on September 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a comprehensive oral evaluation (D0150), and does not have to pay for a panoramic radiographic image (D0330), a pre-diagnostic test (D0431), and an unspecified preventive procedure (D1999) provided on May 21, 2021.
You asked the Plan to waive the copayment for a comprehensive oral evaluation, and to pay for a panoramic radiographic image, a pre-diagnostic test, and an unspecified preventive procedure. You say that the services at issue should be covered. The Plan denied your request. The Plan says the panoramic radiographic images is a covered benefit, but you have exceeded the frequency limit of one every 5 years. The pre-diagnostic test, and an unspecified preventive procedure are not covered benefits.
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 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 $50 copayment for covered benefits. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation, a panoramic radiographic image, a pre-diagnostic test, and an unspecified preventive procedure have not been met. Specifically, the record shows that you had exceeded the frequency limit for the panoramic radiographic image prior to this service on December 12, 2017. Additionally, a pre-diagnostic test, and an unspecified preventive procedure are not covered benefits. Lastly, you have been asked to a $50 copayment for a comprehensive oral evaluation. A comprehensive oral evaluation falls within the dental services 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 a comprehensive oral evaluation (D0150), and does not have to pay for a panoramic radiographic image (D0330), a pre-diagnostic test (D0431), and an unspecified preventive procedure (D1999) provided on May 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from April 8, 2021, to May 4, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care.
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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from April 8, 2021, to May 4, 2021.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pay for psychotherapy services (90837) provided on January 19, 2021.
You asked the Plan to pay for psychotherapy services. You say that this was medically necessary. The Plan denied your request. The Plan says that Medicare payment for psychology services is limited to treatment by practitioners with a Psychology Doctoral degree that are licensed or certified in the State.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided information to substantiate that the provider of the service at issue is not licensed to provide this service. We found that the provider is licensed in the state in which the services were provided in and is a Medicare-enrolled provider. Therefore, we decided that the Plan has to pay for psychotherapy services (90837) provided on January 19, 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: Favorable

We decided that the Plan has to pay for the services (99231) provided on February 11, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that this is not payable.
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, a code pair edit does not exist between codes 01638 and 99231. As
such, code 99231 is payable in this case. The submitted documentation does not substantiate the Plan's denial.
Therefore, we decided that the Plan has to pay for the services (99231) provided on February 11, 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 must 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 physical therapy (PT) visits.
You asked the Plan to pre-approve 20 PT visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 20 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 20 PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 20 physical therapy (PT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound therapy you received from April 5, 2021, to May 28, 2021.
You asked the Plan to pay for the ultrasound therapy. The Plan denied your request. The Plan says this is not a covered service.
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 are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the ultrasound therapy you received from April 5, 2021, to May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on March 24, 2021.
You asked the Plan to pay for the services provided. You say that the enrollee was an inpatient and was billed
as such. The Plan denied your request. The Plan says the rules for payment have not been met.
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 find that CPT code 99153 is a technical component only code and not payable as a professional component.
Based on this information, we decided that Medicare rules for coverage of the services provided have not been
met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on
March 24, 2021.