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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for
care in a SNF. The Plan denied your request. The Plan says the enrollee has not had a change in function that
needs daily skilled therapy services. The Plan says that there are no daily skilled nursing needs. The Plan says
that the enrollee's needs can be met 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 enrollee received oral
medications and insulin. The enrollee had stable vital signs, continued dialysis, and tolerated an oral diet. The
enrollee received physical therapy and occupational therapy. The enrollee was at an independent with bed
mobility, and non-ambulatory at baseline. The enrollee required varying assist with activities of daily living.
There are no identifiable skilled therapy service needs. There are identifiable skilled nursing service needs, but
they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service
criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for
LTACH services. The Plan says that the clinical information shows that the enrollee's needs can safely be met
in the current hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation provided indicating medical necessity for LTACH
services. The enrollee is receiving appropriate care at the present acute care hospital.
The enrollee does not require services at the LTACH that are not available at the acute care hospital where she
is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not
available at the health care setting being offered by the health plan. The requested LTACH services are not
medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be
furnished safely and effectively only on an inpatient basis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3 Finger Naked Prosthetics MCP Driver System (RT)
and a 1 Finger Naked Prosthetics PIP Driver System (LT) for the enrollee.
You asked the Plan to pre-approve these services. You say that these items are medically necessary for the
enrollee. The Plan denied your request. The Plan says that the requested prostheses exceed the member's need.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. There is a lack of
high quality evidence in the literature of functional outcomes for partial hand prosthesis with the requested
body powered Naked prosthetics. Additionally, a review of the specifications reveals that the items exceed the
patient's functional needs.
Per the Naked Prosthetics Product Technical Specifications the prosthetics are designed to get workers back to
difficult jobs, and for people who use their hands in harsh environments. All products are resistant to most
common chemicals such as isopropanol, ethanol, acetone, and oil, as well as water, dust and dirt. The
prosthetics come in multiple color options as well. These features exceed the patient's medical and functional
need and do not meet the criteria for medical necessity. Our physician reviewer found that the enrollee's
condition does not meet 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 not been met. Therefore, we decided that the Plan does not
have to pre-approve a 3 Finger Naked Prosthetics MCP Driver System (RT) and a 1 Finger Naked Prosthetics
PIP Driver System (LT) for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910), provided on
December 16, 2021.
You asked the Plan to pay for the periodontal maintenance (D4910). You say that the service should be
covered. The Plan denied your request. The Plan says you have exhausted the Plan's allowed frequency
amount.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
periodontal maintenance (D4910), provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter insertion rendered on June 9, 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 51702 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically
appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 51702 (insertion of temporary indwelling bladder catheter)
and 52205 (cystoscopy with biopsy). Code 51702 is a column II code with a modifier indicator of 1 when
billed with column I code 52205. Code 51702 was not billed with an appropriate modifier to allow for separate
payment. Therefore, we decided that the Plan does not have to pay for the catheter insertion rendered on June
9, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that home care services would not suffice your cute
care needs. The Plan denied your request. The Plan says based on Medicare guidelines, your request for
approval of admission to skilled nursing facility does not meet the requirements for approval.
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 services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found that from a nursing
perspective, you received oral medications. You had stable vital signs. You used oxygen via nasal cannula.
Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT) in the
SNF. By the dates in question, you were at a standby assist to contact guard assist level with functional
mobility including gait to 240 feet. You required varying assist with activities of daily living. There are no
identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not
require skilled nursing or therapy services on a daily basis. As a practical matter, you do 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT
code(s): 22869 and 22870), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your
request. The Plan says the Vertiflex superion interspinous device is not indicated in this enrollee given multi-
level disease, greater than 2 levels, as seen on the May 15, 2021, magnetic resonance imaging (MRI) of the
spine with canal and foraminal narrowing at L2-L3, and L5-S1 placement of Vertiflex at L3-L5 will not
address the stenosis at the other levels.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Vertiflex spacer is experimental. More research is needed to show safety and efficacy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve the Vertiflex superion device placement surgery (CPT code(s): 22869 and 22870), for the
enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan
denied your request. The Plan says based on Medicare guidelines and the information we have about your
condition; you don't meet the requirements.
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 health Plan's denial should be
upheld. 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.
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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) coded C1734 and related services provided on June 8, 2021.
You asked the Plan to pay for the orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 C1734 is orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable). We find that CPT code C1734 is not supported in the medical record. Specifically, this device described by code C1734 should always be billed with one of the following codes: CPT code 27870 (Arthrodesis, ankle, open) which is assigned to APC 5115 for Calendar Year (CY) 2020, CPT code 28705 (Arthrodesis; pantalar) which is assigned to APC 5116 for Calendar Year (CY) 2020, CPT code 28715 (Arthrodesis; triple) which is assigned to APC 5115 for Calendar Year (CY) 2020, or CPT code 28725 (Arthrodesis; subtalar) which is assigned to APC 5115 for Calendar Year (CY) 2020. Review of the file does not support that this device was billed with one of these codes. Based on this information, we decided that Medicare rules for coverage of the orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) and related services have not been met. Therefore, we decided that the Plan does not have to pay for the orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) coded C1734 and related services provided on June 8, 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 higher level of care has been recommended. You
say that a skilled nursing facility level of care is not sufficient. You say that you were 100% independent living
and active in your community prior to contracting coronavirus. The Plan denied your request. The Plan says the
guidelines for coverage of IRF care have not been met. The Plan says that the enrollee's 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. Our physician reviewer found 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. The enrollee was admitted for weakness and hyponatremia after recent hospitalization for
Coronavirus pneumonia. The enrollee's medical problems are stable. There are no complex nursing or
rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need
for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation
program. There is not a reasonable expectation that the 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the member has injuries to her spine and cannot return home at this time. The Plan denied your request. The Plan says that the request does not show that the enrollee has skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, your request for approval of admission to skilled nursing facility does not meet the requirements for approval.
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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, you received oral medications. You had stable vital signs. You tolerated dialysis. Regarding rehabilitation services, you received physical therapy (PT) and occupational therapy (OT). You were at a standby assist/supervision to contact guard assist level for functional mobility including gait to 50 feet with a rolling walker. You required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. As a practical matter, you do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81001) provided August 24, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the billed code is not separately payable.
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, we have confirmed that code 81001
shares a bundled relationship with code G0483 which was also billed. This claim has not been billed with an
appropriate modifier to bypass the edit.
Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan
does not have to pay for lab services (81001) provided August 24, 2020
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 13, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that you were taken to the hospital but they didn't treat you. You said that you were taken to the hospital due to a joke you said. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency room services. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the ER visit or the extent of services received.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on July 13, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided to the enrollee on June 30, 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 a modifier was not billed on the claim to represent the services as separate and distinct.
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, we have confirmed that code 93010 the services is a column II code to column I code 93295. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) provided to the enrollee on June 30, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on October 21, 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 were not billed correctly.
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 October 21, 2020.