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

We decided that the Plan does not have to pay for the removal of impacted cerumen rendered on September 14, 2020.
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 services are not separately payable.
The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable. The provider submitted a claim for procedure codes 92557 (comprehensive hearing test) and 69210 (removal of impacted cerumen). Code 69210 is a column II code with a modifier indicator of 0 when billed with column I code 92557 and is not separately payable. Therefore, we decided that the Plan does not have to pay for the removal of impacted cerumen rendered on September 14, 2020.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission. 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care and treated for a stroke, currently in IRF. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the acute hospital. The enrollee was at a maximal assist to dependent level with functional mobility and required a mechanical lift for transfers. The enrollee required varying assist with activities of daily living. He had impaired attention and memory. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 admission to a SNF 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 a lightweight wheelchair (K0003).
You asked the Plan to pre-approve the lightweight wheelchair. You say that the manual lightweight wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a lightweight wheelchair is covered when an enrollee cannot self-propel in a standard wheelchair. 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 lightweight wheelchair. Our reviewer says that the requested wheelchair is not medically necessary. Our physician reviewer found the clinical information provided does not show the patient is unable to self-propel a standard wheelchair. 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 lightweight wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a lightweight wheelchair (K0003).
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 the SNF admission. You say that the enrollee cannot walk by herself and can only stand if someone is holding her. The appellant says that the enrollee cannot go to the bathroom and her home is not handicap accessible. She cannot use her left arm and is currently having physical, occupational, and speech therapy. The Plan denied your request. The Plan says the enrollee is receiving adequate and necessary intensive rehabilitation in the inpatient rehabilitation facility (IRF). The Plan says that movement to a SNF is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who was hospitalized with an acute stroke resulting in left sided weakness. She was transferred to an inpatient rehab facility on 8/11/21 for services. She has made slow progress due to complicating infections with c. difficile and urinary tract infections. She is now medically stable. The most recent therapy documentation indicates the member is continues to require extensive assistance with self-care tasks and mobility. The member has stabilized medically and has been receiving skilled rehab services in an inpatient rehabilitation facility (IRF). The member has tolerated inpatient rehab services and continues to improve with daily skilled nursing and/or skilled therapy services. She could benefit from continued services at the current level of care. The member has made slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. She can continue to receive skilled rehab services at the current IRF or be stepped down to a lower level of care when appropriate. 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 admission 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: 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 admission. You say that the enrollee needs mobility assistance to regain normal function. The enrollee cannot wait 30 days for these necessary therapy services. The Plan denied your request. The Plan says the records do not show that the enrollee requires daily skilled services that can only be provided on an inpatient basis. The Plan says that the services needed can safely be received at a different setting. 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a male with left humerus fracture, bipolar disorder and acute kidney injury. From a nursing perspective, the beneficiary received oral medications. The beneficiary had stable vital signs. He was treated for pain with effect. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the acute hospital. The beneficiary was at a supervision level with functional mobility including gait. The beneficiary required varying assist with other daily living activities. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require the services of a qualified therapist on a daily basis. This beneficiary 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 SNF admission 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 24, 2021 by an out-of-network
(OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan
denied your request. The Plan says prior authorization was not obtained by the member's primary care
physician. The Plan says that the referring provider is also 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 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 lab work provided on February 24, 2021 by an
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the service dog support benefit.
You asked the Plan to pre-approve the service dog support benefit. You say that you do not agree with the Plan's denial. The Plan denied your request. The Plan says your provider listed anxiety as the supporting diagnosis for the qualification for a service dog. Anxiety is not listed as an eligible chronic illness under the Plan's service dog support benefit.
The Plan contract offers a supplemental Service Dog Support benefit. We looked at the file and the Plan's rules. The file shows that the Plan does not cover the service dog support benefit for enrollees with anxiety as the supporting diagnosis. Based on this information, we decided that the Plan's rules for coverage of service dog support benefit have not been met. Therefore, we decided that the Plan does not have to pre-approve the service dog support benefit.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional supplies and materials rendered from February 23, 2021 to February 25, 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 procedure code 99072 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure code 99072 (additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease) has a status indicator of B and is not separately payable. Therefore, we decided that the Plan does not have to pay for the additional supplies and materials rendered from February 23, 2021 to February 25, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 13, 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 the services were billed incorrectly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 13, 2021.
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 the SNF services. You say that the SNF level of care is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission the a SNF. The Plan says that the care needed could be provided at a lower 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 pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the beneficiary is a male who underwent a recent elective right knee replacement. From a nursing perspective, the beneficiary received oral medications and had stable vital signs. He was treated for pain. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the acute hospital. The beneficiary was at a stand by assist to contact guard assist level with functional mobility including gait to 50 feet with a rolling walker. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs; however, these do not require the services of a qualified therapist on a daily basis. This beneficiary 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 pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
You asked the Plan to pre-approve twelve (12) additional PT visits. You say that the PT visits are medically necessary. The Plan denied your request. The Plan says the PT visits are not medically necessary.
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 twelve (12) additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found based on the medical records provided there is no documentation that the requested therapy is generally accepted as specific and effective therapy for the enrollee's condition. Based on the available records the enrollee appears to have improved with therapy to the point of being able to manage some work on his farm. Nothing in the available records clarifies why the twenty-four (24) approved visits are inadequate to manage the enrollee's condition and why a home exercise program would not be appropriate at this point. There is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain the enrollee's 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 twelve (12) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve twelve (12) additional PT visits.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve diagnostic MBBs at two levels bilaterally. We decided that the
Plan does not have to pre-approve MBBs at more than two levels.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that
the services are not medically necessary.
We decided that the Plan has to pre-approve diagnostic MBBs at two levels bilaterally.
The rules say that MBBs are covered at two levels bilaterally when specific criteria are met.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
MBBs at two levels are medically necessary. Our physician reviewer found the enrollee has chronic low back
pain. She had radiofrequency ablation at four levels bilaterally in 2018 and again in 2019. The Medicare
criteria limits MBBs to two levels bilaterally per sessions. Two levels are reasonable and medically necessary.
We looked at this physician's review, the file, and Medicare rules. The physician states that the services are
medically necessary at two levels. 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 diagnostic MBBs at two
levels bilaterally.
We also decided that the Plan does not have to pre-approve MBBs at more than two levels.
We looked at this physician's review, the file, and Medicare rules. The physician states that the services are not
medically necessary at more than two levels. 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
MBBs at more than two levels.
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: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your
request. The Plan says that the criteria is not met, and a home glucose monitor is more appropriate.
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 any medical records for review in this case. Their
denial is based on medical records, so they must substantiate their denial in this case. Therefore, we decided
that the Plan has to pre-approve a continuous glucose monitor.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray exam of the hip (73502) and the x-ray exam of the
knee (73560) rendered by the out-of-network (OON) provider on January 11, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of
network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal.
The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay
for these services. Therefore, we decided that the Plan does not have to pay for the x-ray exam of the hip
(73502) and the x-ray exam of the knee (73560) rendered by the out-of-network (OON) provider on
January 11, 2021.
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 admission to a SNF. You say that the requested admission to a SNF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is with dementia, hypertension, coronary artery disease, hyperlipidemia and a fall with fractured wrist and lumbar compression fracture. From a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Her lungs were clear. She was treated for pain. Regarding rehabilitation services, the enrollee received physical therapy in the acute hospital. The enrollee was at a moderate to minimal assist level with bed mobility and transfers. She was non-weight bearing to her right upper extremity. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).