Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically 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 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 dehydration, weakness, and pancolitis. She was discharged home on 9/3/21 and has had multiple episodes of falling despite home health physical therapy services. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided to the enrollee from March 25, 2021, to April 23, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says SNF 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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The 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 the services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of skilled nursing facility (SNF) services provided to the enrollee from March 25, 2021, to April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided to the enrollee on September 15,
2020.
You asked the Plan to pay for the medical services. You say that the procedures were medically necessary. The
Plan denied your request. The Plan says the billed codes are not supported by documentation.
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 27503 is 'closed treatment of supracondylar or
transcondylar femoral fracture with or without intercondylar extension, with manipulation with or without skin
or skeletal traction' and the CPT Code Manual definition of Code 27520 is 'closed treatment of patellar
fracture, without manipulation.'
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 medical procedures. Our reviewer says that the medical
records do not support the services billed. Our reviewer found the operative report does not include
documentation of closed treatment of femoral or patellar fracture.
The operative report describes debridement and irrigation at site of open fracture. Therefore, CPT 27503 and
CPT 27520 cannot be confirmed as performed by documentation submitted.
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 medical services have not been met. Therefore, we decided that the Plan
does not have to pay for medical services provided to the enrollee on September 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after
September 15, 2021.
You asked the Plan to pre-approve SNF care. You say that the opinion of the facility staff is that the enrollee
fully meets the criteria of medical necessity and cannot receive services at home. The Plan denied your request.
The Plan says the denial of authorization for continued SNF care after September 15, 2021 is correct.
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 enrollee does not have daily skilled
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. While
the enrollee does have skilled therapy needs, these needs are not on a daily basis. The enrollee does not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a
skilled nursing facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve continued skilled nursing facility (SNF) care after September 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on December 21, 2020, billed with codes 87015, 87070, 87075, 87102, 87116, and 87205.

You asked the Plan to pay for the lab testing billed. You say that these are not duplicate claims and both should be paid as there were separate specimens submitted for testing. The Plan denied your request. The Plan says this is an exact duplicate of a claim that was already paid. As such, the denial is correct.

The Plan must follow Medicare rules. Medicare rules say that exact duplicate claims will be denied, though appeals can be submitted to support payment.

In this case, though there were multiple samples, the record does not reflect that the exact same testing was performed on more than one sample to justify that a second claim for the same codes is payable. We find that this is correctly denied as a duplicate claim. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on December 21, 2020, billed with codes 87015, 87070, 87075, 87102, 87116, and 87205.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee from February 25, 2021, to February 27, 2021.

You asked the Plan to pay for the services. You say that the claim was properly billed. The Plan denied your request. The Plan says the secondary diagnosis of R18.8 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

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 review indicates that the progress notes contain documentation stating that, "small volume abdominal pelvic ascites was noted on the CT scan. The discharge summary states that, "CT was performed. There is small volume abdominal pelvic ascites and notes final diagnoses of, "abdominal pain with resolution, partial small bowel obstruction, abnormal CT, and enteritis, now improved." In this case, the submitted documentation states that ascites was noted on the CT; however, it did not state how this finding had a bearing on the care being provided.

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 hospital services provided to the enrollee from February 25, 2021, to February 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the tooth addition to an existing partial denture (D5650) provided on April 6, 2021.
You asked the Plan to pay for the tooth addition. You say that you did not know that this service was not a covered benefit under your plan. The Plan denied your request. The Plan says this service is not covered under your benefit plan.
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 tooth addition to an existing partial denture (D5650) provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient hospital admission.
You asked the Plan to pre-approve an inpatient hospital admission. You say that the records provided support the need for an inpatient hospital admission. The Plan denied your request. The Plan says the enrollee's condition does not meet the requirements for coverage of an inpatient admission. The Plan says that an inpatient hospital admission isn't associated with the procedure being provided.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient hospital admission.
Our reviewer says that the documentation does not support that the criteria for an inpatient hospital admission are met in this case. Our physician reviewer found an inpatient stay is not medically needed for this routine total knee replacement surgery. The knee replacement may be safely performed with an observational stay of 48 hours. 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 inpatient hospital admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient hospital admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide reimbursement for the Pioneer 9 DLX Group 2 power scooter coded as K0807 with accessories with a three-year in-home service plan, and a heavy duty platform lift purchased on December 23, 2020, and January 5, 2021.

You asked the Plan to provide reimbursement for the Group 2 power scooter and platform lift. You say that your doctor contacted the network provider and requested a power scooter, but you were told to look elsewhere for a supplier that could accommodate your weight/size. You did this but now are being denied reimbursement. You feel that this should be covered because you were told to find another provider and no network provider could give you the chair you needed. The Plan denied your request. The Plan says this is denied as out of network since no authorization was requested for this item.

The Plan must follow Medicare rules. Medicare rules say that DME is only eligible for coverage when it is needed for use in the home. Group 2 power scooters have added capabilities that are not necessary for use in the home. As such, these are denied as not medically necessary.

Although a power scooter may be appropriate for you, this specific type of power scooter is not covered by Medicare. In addition, the platform lift is for use outside the home only and is also not eligible for coverage. Therefore, we decided that the Plan does not have to provide reimbursement for the Pioneer 9 DLX Group 2 power scooter coded as K0807 with accessories with a three-year in-home service plan, and a heavy duty platform lift purchased on December 23, 2020, and January 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided on April 2, 2021.

You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. 

The record does not contain a valid proof of delivery for the supplies provided in this case. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the durable medical equipment provided on April 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services.

You asked the Plan to pre-approve physical therapy services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve physical therapy services.
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 in this case, the enrollee has previously
been treated with outpatient therapies and should be independent with a home exercise program. There is no
documentation of a recent injury or decline in function and the documentation indicates a lack of continued
meaningful improvement. The additional therapy services are not an appropriate duration and frequency for
treatment of the enrollee's medical condition and therefore are 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 physical therapy services have not been met. Therefore, we decided that the
Plan does not have to pre-approve physical therapy services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable oxygen equipment received on March 29, 2021.

You asked the Plan to pay for the portable oxygen equipment. You say that when your power went out you
were without oxygen, so you need a portable unit. The Plan denied your request. The Plan says they do not
cover purchases of oxygen equipment, only rentals.

The Plan must follow Medicare rules. The rules only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered.

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 portable oxygen equipment have not been met. Therefore, we decided that
the Plan does not have to pay for the portable oxygen equipment received on March 29, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown you received on May 12, 2021.
You asked the Plan to pay for the crown. You say that this should be covered. The Plan denied your request. The Plan says you are responsible for the coinsurance.
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 services are subject to a cost share responsibility. You have been asked to pay a 50% coinsurance for the crown. This means that you have been asked to pay the correct amount as outlined in your Plan contract. Therefore, we decided that the Plan does not have to pay for the crown you received on May 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from January 1,
2021, to February 10, 2021.
You asked the Plan to pay for SNF care. You say that SNF care was medically necessary. The Plan denied your
request. The Plan says you did not meet Medicare criteria for coverage of SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found that the medical records do not document
daily skilled nursing needs. There is no documentation of his medical conditions, physical or occupational
therapy evaluations or progress notes. Documentation did not support the need for SNF care in this case.
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 pay for skilled nursing facility (SNF) care provided from January 1, 2021, to February 10, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the expandable controller, harness, and related electronic connections to be provided with an approved power wheelchair.

You asked the Plan to pre-approve the expandable controller and related hardware. You say that this is needed. The Plan denied your request. The Plan says you will be able to use the power seating features with their own switches. There is no need for this to be controlled through the main drive control.

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 expandable controller and related hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the expandable controller is medically reasonable and necessary for the enrollee in this case. The enrollee is expected to the control power options using their own switches. 

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 expandable controller and related hardware have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller, harness, and related electronic connections to be provided with an approved power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on June 9, 2020.
You asked the Plan to pay for the lab testing. You say that this was medically necessary and could not be delayed when the sample was received. The Plan denied your request. The Plan says this was billed with the incorrect POS code.
The Plan must follow Medicare rules. Medicare rules say that for lab services, the POS code must reflect the location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory directly. The documentation does not support that this sample was taken directly by the laboratory. As such, POS code 81 is not supported. Therefore, we decided that the Plan does not have to pay for the laboratory testing provided on June 9, 2020
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the pelvis x-ray interpretation provided on April 24, 2021, billed with code 72170-GC-26.
You asked the Plan to pay for the pelvic x-ray interpretation. You say that these were separate x-rays and should both be paid. The Plan denied your request. The Plan says there was not an NCCI modifier reported with the Column 2 code to allow for payment.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports two codes of an edit pair, only the Column 1 code is payable. 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.
In this case, code 72170 is a Column 2 code in relation to code 73502 (Radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views). A clinically appropriate NCCI modifier was not used. As such, it cannot be separately paid. Therefore, we decided that the Plan does not have to pay for the pelvis x-ray interpretation provided on April 24, 2021, billed with code 72170-GC-26.