Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided February 5, 2021 to February 10, 2021 and February 15, 2021 to February 28, 2021

You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover the SNF services provided. The Plan denied your request. The Plan says the Medicare criteria for continued SNF level of coverage were not met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided February 5, 2021 to February 10, 2021 and February 15, 2021 to February 28, 2021
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optimesh cage (22853).

You asked the Plan to pre-approve an Optimesh cage. You say that the requested procedure is a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met
because the requested procedure is experimental/investigational.

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 an Optimesh cage. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found that the Optimesh cage remains experimental. More research needed to show the
safety and efficacy of synthetic cages in spine surgery.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of an Optimesh cage have not been met. Therefore, we decided that the Plan does
not have to pre-approve an Optimesh cage (22853).
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 inpatient rehabilitation care is the best choice for the
enrollee's recovery. The Plan denied your request. The Plan says the criteria for admission to an IRF are not
met. The enrollee's ongoing care needs can be met in a less intensive setting.

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 the enrollee's 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 this enrollee
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: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit (99215} provided on January 13, 2021 to February 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that you agreed to see the provider as private pay because the provider did not accept the Plan. You were told by customer service that you would be reimbursed for the services. The Plan denied your request. The Plan says prior authorization was not obtained because the enrollee agreed to private pay.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for the outpatient office visit (99215} provided on January 13, 2021 to February 22, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81405, 81404, 81403, 81401, 81406, 81407, and 81408) provided to the enrollee on December 8, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says this provider has not submitted ay clinical records to support the medical necessity of the service(s). The Plan states that mutually exclusive edits consist of combinations of procedures that differ in technique or approach but lead to the same outcome. The Plan states that in some instances, the combination or procedures may be anatomically impossible, procedures that represent overlapping services are considered mutually exclusive. The Plan state reporting an initial service and subsequent service is considered mutually exclusive. The Plan states the laboratory testing billed and denied are considered redundant to the testing allowed.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Additionally, this testing was not billed with the appropriate CPT codes for Cardiovascular Disease Screening. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT code(s): 81405, 81404, 81403, 81401, 81406, 81407, and 81408) provided to the enrollee on December 8, 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 the enrollee is motivated to improve and will tolerate the three hours of therapy required of acute rehabilitation. The Plan denied your request. The Plan says an IRF stay is not reasonable or 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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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: 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. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary approach to 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 physician reviewer found that the enrollee is at a standby assist level for bed mobility, minimal assist for transfers, and minimal assist for walking. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.

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 Mental Health
Decision: Favorable

We decided that the Plan has to pay for individual psychotherapy session performed by a licensed mental health provider, 60 minutes (90837) provided April 12, 2021.

You asked the Plan to pay for the psychotherapy services. You say that the enclosed medical records clearly reflect the medical necessity for the services rendered. The Plan denied your request. The Plan says that Medicare payment for clinical psychology services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with patient consent and consult with discussion and involvement with the attending or primary care physician.

The Plan must follow Medicare rules. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. 

In this case, the plan is denying services by a clinical psychologist and using the criteria for a clinical psychologist. This provider is a licensed clinical social worker (LCSW). LCSW's are eligible for payment and the Plan has not addressed any of the criteria mentioned in the case file. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have been met. Therefore, we decided that the Plan has to pay for individual psychotherapy session performed by a licensed mental health provider, 60 minutes (90837) provided April 12, 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 therapeutic CGM (CPT code K0553) provided to the enrollee on March 22, 2021.

You asked the Plan to pay for the CGM. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Documentation submitted did not sufficiently document the enrollee's medical condition to support the medical necessity for the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code. Documentation submitted did not include Proof of Delivery or an itemized invoice, packing slip, or Delivery Ticket for the date of service being appealed to indicate the specific supplies, therefore the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for the therapeutic CGM (CPT code K0553) provided to the enrollee on March 22, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Venofer.

You asked the Plan to pre-approve Venofer. You say that this drug is medically necessary. The Plan denied
your request. The Plan says the criteria for coverage have not been met.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDAapproved
drugs if they are medically accepted as safe and effective or appropriate for the particular use.

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 Venofer. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that in this
case, the enrollee's iron levels do not support the diagnosis. The iron levels in this case do not support that the
enrollee has been diagnosed with iron deficiency anemia as required for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Venofer have not been met. Therefore, we decided that the Plan does not have
to pre-approve Venofer.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport (A0429) and ground mileage, per statute mile (A0425) provided March 9, 2021.

You asked the Plan to pay for the emergency ambulance services. You say that you would like the ambulance services covered. The Plan denied your request. The Plan says your condition was not emergent, and you were not in distress and therefore the ambulance service is not covered.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

We looked at the file and Medicare rules. In this case, the enrollee's urinary catheter was cut. A prudent layperson would believe that without immediate medical attention there would be serious jeopardy to the enrollee's health in this case. Based on this information, we decided that Medicare rules for coverage of the emergency ambulance services have been met.

Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life support, emergency transport (A0429) and ground mileage, per statute mile (A0425) provided March 9, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for you. The Plan denied your request. The Plan says rules for SNF care have not been met because the request 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 that the enrollee does not have documented skilled nursing needs or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the medical record is reviewed in its entirety. The member has stabilized medically and is ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab 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 skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab 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 admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional mask interfaces.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. The rules say that one face mask interface described by procedure code
A7035 is approved every six months.

We looked at the file and Medicare rules. The services at issue are six additional face mask interfaces described
by code A7035. The Plan has already approved six additional masks. Six further exceed the approved limit in
the 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 six additional mask
interfaces.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for SNF care have not been met because the
requested level of care 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 that the enrollee does not have documented
skilled nursing needs or skilled therapy needs. Daily skilled services are not required to establish a maintenance
program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, 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 SNF care.
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 ongoing skilled therapy and nursing needs can be provided at 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. 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 surgical repair of a hip fracture
after a fall. 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.