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

We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements were not met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found this is not medically necessary based on the MRI findings, the lack of an amyloid PET scan, and questions about the accuracy of the CSF analysis. The documentation does not support that the requested drug is medically reasonable, safe, effective and necessary for the 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you need inpatient rehabilitation services in order to return to your prior level of function and independence. The Plan denied your request. The Plan says the criteria for an IRF are not met. You can safely receive the services you need in another 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 based on the provided documentation, the health Plan's denial is appropriate. You do not require the intensity of services provided at an IRF. Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. Your care needs can be met in a less intensive 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing visits, 15 minutes each, for 4 hours per
week for 9 weeks.

You asked the Plan to pre-approve the home health services. You say that the requested care is medically
necessary. The Plan denied your request. The Plan says the bowel program is not a skilled nursing need. The
Plan also says that the enrollee requires assistance with management of medications and a catheter.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer
says that the home health services are not medically necessary. Our physician reviewer found the medical
records provided do not indicate that skilled nursing services are required for the care related to the bowel
program. The reviewer also found that the requested services related to the bowel program are not a skilled
nursing need.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the home health services have not been met. Specifically, the requested services
do not require a skilled nurse. Therefore, we decided that the Plan does not have to pre-approve skilled nursing
visits, 15 minutes each, for 4 hours per week for 9 weeks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ramps and rails.

You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says the items
are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve ramps and rails.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device.

You asked the Plan to pre-approve the device. You say that this is is medically necessary. The Plan denied your request. The Plan says there is a lack of reliable evidence in the literature to support the use of this device.

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 not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. This device is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase participation in bimanual activities.

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 a powered upper extremity range of motion assist device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services billed with DRG 871 provided from January 21, 2019, to February 4, 2019.

You asked the Plan to pay for the inpatient services as billed. You say that the documentation supports DRG 871 and the primary diagnosis of sepsis. The Plan denied your request. The Plan says the hospital record does not support reporting the diagnosis code for Sepsis for this clinical encounter.

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 principal diagnosis code A41.9, defined as Sepsis, unspecified organism. 

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 inpatient services as billed. Our reviewer says that the submitted DRG is not supported. Our physician reviewer found that the hospital record did not support reporting the diagnosis code for Sepsis for this clinical encounter. Our reviewer also found that the hospital asserts that the presence of elements of the systemic inflammatory response syndrome (SIRS) is sufficient to establish the diagnosis of sepsis. However, these findings are not sufficient to establish this diagnosis. 

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 services billed with DRG 871 provided from January 21, 2019, to February 4, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 18, 2021, to March 16, 2021.
You asked the Plan to pay for the skilled nursing services. You say that while you were in the home you were rehabilitating and recovering from a hip accident. The Plan denied your request. The Plan says you did not meet the criteria for skilled nursing coverage.
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 you did not meet the Medicare criteria for SNF care. Our physician reviewer found you did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you 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 February 18, 2021, to March 16, 2021.
Appeal type: Drugs
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 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 you do 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 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 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. The Plan denied your request. The Plan says you are not able to
actively participate in 3 hours of therapy a day.

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 you were admitted to the acute care hospital for non-surgical management of an arm fracture after a fall
and for a urinary tract infection. Your medical problems are stable. There are no complex nursing needs. You
do not require treatment by multiple therapies in an intensive rehabilitation therapy program.

There is not a reasonable expectation that you will be able to fully participate in and benefit from the 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.

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 moderate sedation services (G0500) provided to the enrollee on April 12, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says Healthcare Common Procedure Coding System (HCPCS) G0500 remains not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code G0500 is "Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra-service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)."

We asked our coder 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 reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the procedure report does not include documentation to support the entire description of the denied code. HG0500 includes the presence of an independent trained observer to assist in monitoring, which is not documented in the report submitted. Therefore, this procedure cannot be confirmed as performed. 

We looked at this coder'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 moderate sedation services (G0500) provided to the enrollee on April 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for laboratory services and a CT scan
provided on June 1, 2021.
You asked the Plan to reduce the copayment for laboratory services and a CT scan. You say that you were sent
to the facility from your provider's office. You state that you were not actually seen in the emergency room
(ER), however, since you went there you feel the ER copay is all you should be charged. The Plan denied your
request. The Plan says you have been charged the correct cost sharing amount.
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 $30
copayment for in-network laboratory services and a $270 copayment for an in-network CT scan.
Although you were seen at an out-of-network facility, the lower, in-network rates have been applied. You have
been asked to pay a $30 copayment for laboratory services and a $270 copayment for a CT scan, for a total of
$300. CT scans and laboratory services fall within the Outpatient Diagnostic Tests and Therapeutic Services
and Supplies 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 reduce the copayment for laboratory services and a
CT scan provided on June 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program.
There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic testing provided as part of intraoperative neuromonitoring (IONM) provided on November 11, 2020, billed with codes 95885, 95887, 95909, and 95957.
You asked the Plan to pay for the testing services as billed. You say that this was coded correctly and should be paid. The Plan denied your request. The Plan says these codes are not supported by the records submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95885 is Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure. Code 95887 is Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primary procedure). Code 95909 is Nerve conduction studies; 5-6 studies. Code 95957 is Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). We asked our coder 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 testing services as billed. Our reviewer says that the codes billed are not supported. Our reviewer found the medical records provided do not include sufficient documentation to support billing 95885 because pedicle screw stimulations do not meet criteria of baseline nerve conduction studies. Code 95909 is not supported for the same reason. 95887 is not supported as the medical records provided do not include sufficient documentation to support that a nerve conduction study was performed, which is a requirement for 95887 to be considered for reimbursement. Finally, the medical records provided do not include sufficient documentation to support that a Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) was performed on November 11, 2020. Real time Electroencephalogram monitoring is not covered under CPT code 95957. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic testing provided as part of intraoperative neuromonitoring (IONM) provided on November 11, 2020, billed with codes 95885, 95887, 95909, and 95957.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 20, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the laboratory services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.

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 laboratory services provided on October 20, 2020 by an out-of-network (OON) provider.