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 SNF services. You say that the enrollee needs to improve functional
mobility and activities of daily living. The Plan denied your request. The Plan says the enrollee has not
completed her full course of care in the inpatient rehabilitation facility.
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 physician reviewer
found that the enrollee is walking with maximum assistance with a wide based quad cane and is moderate assist
for transfers and moderate to total assist with activities of daily living. Her diet has been upgraded from pureed
to soft. She is reported to be slowly progressing towards goals and benefitting from therapy in the rehabilitation
facility. The enrollee does not require the services of a professional nurse to provide treatment. Although the
enrollee requires skilled therapy services, she does not need skilled nursing or therapy services on a daily 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 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 acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the service is medically necessary. The Plan denied
your request. The Plan says the service 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 your medical conditions are stable and you have no complex medical nursing or
rehabilitation needs.
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. Specifically, medically necessary services can be
obtained in a lower level of care. This means admission into an IRF is not medically necessary or reasonable.
Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF)
admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that you would like an LTACH admission covered. The Plan denied your request. The Plan says you are receiving appropriate in-patient acute care and do not require transfer to an LTACH.  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 that you appear to be more stable and improving and only short-term acute care services are needed to further stabilize. You can be safely treated at the current facility. You do not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that you require that are not already available and covered at the current facility. Transfer to LTACH would not be clinically advantageous and so will be considered not medically necessary. Transfer to a lower level of care may be considered when treatment has completed.  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 long term acute care hospital (LTACH) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on August
25, 2021.
You asked the Plan to pay for the electric stimulation therapy. You say that you would like reconsideration
based on the records submitted. The Plan denied your request. The Plan says the requested code is not valid for
Medicare.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 97014 is not supported in the record. Specifically, CPT code 97014 has a status
indicator of I. This means that CPT code 97014 is not valid for Medicare purposes. Based on this information,
we decided that Medicare rules for coverage of the electric stimulation therapy have not been met. Therefore,
we decided that the Plan does not have to pay for the electric stimulation therapy (97014) provided on August
25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient psychotherapy services provided from April
19, 2021, to October 19, 2021, by an OON provider.
You asked the Plan to pay for the psychotherapy services. You say that this is the best psychiatrist you have
seen and have developed a bond and trust her. You have been going to her for 5 years. The Plan denied your
request. The Plan says enrollee's must receive their medical services from an in-network provider with the
exception being urgent or emergent services. Non-emergent services with non-contracted providers require
prior authorization before services being rendered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the outpatient psychotherapy services provided
from April 19, 2021, to October 19, 2021, by an OON provider.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home sleep study.  You asked the Plan to pre-approve a home sleep study. The Plan denied your request. The Plan says a home sleep study is not medically necessary based on the Medicare and Medicaid Services, Local Coverage Determinations for Polysomnography and Other Sleep Studies (L36839) and eviCore's Sleep Management Guidelines.  The Plan follows Medicare rules. Medicare rules say that that a follow-up polysomnography or a cardio-respiratory sleep study is indicated for the following conditions: To evaluate the response to treatment (CPAP, oral appliances or surgical intervention); after substantial weight loss has occurred in patients on CPAP for treatment of sleep-related breathing disorders to ascertain whether CPAP is still needed at the previously titrated pressure; after substantial weight gain has occurred in patients previously treated with CPAP successfully, who are symptomatic again despite continued use of CPAP, to ascertain whether pressure adjustments are needed; or when clinical response is insufficient or when symptoms return despite a good initial response to treatment with CPAP.  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 a home sleep study. Our reviewer says that a home sleep study is not medically necessary. Our physician reviewer found that the record indicates that the enrollee had a previous sleep study with the diagnosis of obstructive sleep apnea and was treated with CPAP. The record indicates that the enrollee no longer uses CPAP as the symptoms have resolved and he has no issues with sleep and is well-rested during the day. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a home sleep study.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freedom Proteor microprocessor knee requested
with CPT codes L5856, L5828, L5848, L5845, L5850 and L5925.
You asked the Plan to pre-approve the Freedom Proteor microprocessor knee. You say that you would like
reconsideration because the requested knee is medically necessary. The Plan denied your request. The Plan
says the notes from the member's physician do not show any medical reason to support this or to show why a
mechanical K3 knee cannot be used for the member's initial prosthesis.
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 Freedom Proteor microprocessor
knee. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found there is no documentation of a functional need for the
technologic or design feature of the K3 microprocessor knee as opposed to a mechanical knee to meet
Medicare criteria for coverage. The provided medical records include an office visit note indicating the enrollee
should continue non-weight bearing status with the right lower extremity. An addendum to this note was added
after the health plan initially denied the requested prosthesis and K3 microprocessor knee stating that the K3
microprocessor knee was now indicated. No updated examination or history was provided in the addendum to
fully explain why the microprocessor knee was the most appropriate device for the enrollee's condition. Overall
there is lack of sufficient medical documentation to meet Medicare criteria for the requested microprocessor
knee.
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 Freedom Proteor microprocessor knee have not been met. Therefore, we
decided that the Plan does not have to pre-approve the Freedom Proteor microprocessor knee requested with
CPT codes L5856, L5828, L5848, L5845, L5850 and L5925.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on March 15, 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 15734 is 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 code 15734 is muscle, myocutaneous, or fasciocutaneous flap;
trunk.
We find that CPT code 15734 is not supported in the medical record. Specifically, there is no documentation of
a muscle, myocutaneous, or fasciocutaneous flap of the trunk. 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 pay for the surgical services rendered on March 15, 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. The Plan denied your request. The Plan says criteria for admission
to the Acute Inpatient Rehabilitation setting have not been met.
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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer
found that the patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our
physician reviewer also found that there is not a reasonable expectation that this patient 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 waive the copayment for a specialist visit provided on June 7, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that the provider said that you would
not owe a copayment for the visit. The Plan denied your request. The Plan says the claims were processed
correctly, and you are being charged the correct 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 $50
copayment for specialist visits.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the
physician/practitioner services, including doctor's office visits 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 waive the copayment for a specialist visit provided on June 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the gastric tube placement rendered on September 19, 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 are 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 43752 (naso/oro gastric tube placement) and 99232
(subsequent hospital care). Code 43752 is a column II code with a modifier indicator of 1 when billed with
column I code 99232. Code 43752 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 gastric tube placement rendered on September
19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for specialist office visits (99204, 99213)
provided by an out-of-network provider on August 2, 2021, and August 28, 2021. You also asked the Plan to
waive the coinsurance for aspiration and/or injection of fluid to a large joint using ultrasound guidance (20611)
provided by an out-of-network provider on September 13, 2021.
You asked the Plan to waive the coinsurance for specialist office visits and joint aspiration. You say that the
provider did not inform you that your insurance would not fully cover the expenses for the services you
received. The Plan denied your request. The Plan says the cost-sharing was applied 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 20%
coinsurance for Physician/Practitioner Services, Including Doctor's Office Visits.
You have been asked to pay a cost-share of $73.75 for specialist office visits and joint aspiration. The services
at issue fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. The
Plan indicates that the claims were assessed at the in-network benefit level despite the providers' out-of-
network status. See below for a breakdown of your cost-share.
Date of service August 2, 2021
Allowed Amount $171.97  20% coinsurance = $34.39
Date of service August 27, 2021
Allowed Amount $93.83  20% coinsurance = $18.77
Date of service September 13, 2021
Allowed Amount $102.94  20% coinsurance = $20.59
$34.39 + $18.77 + $20.59 = $73.75
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 coinsurance for specialist office visits (99204, 99213) provided by an out-
of-network provider on August 2, 2021, and August 28, 2021. You also asked the Plan to waive the
coinsurance for aspiration and/or injection of fluid to a large joint using ultrasound guidance (20611) provided
by an out-of-network provider on September 13, 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 you would like to request a redetermination on the
benefits and allowances of the enrollee, providing him with the quality treatment and management needed to
access his physical abilities adequately. The Plan denied your request. The Plan says the IRF services you are
requesting do not meet the requirements for approval.
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 patient's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Our reviewer
found that the patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical
and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. Our
physician reviewer also found that there is not a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vulvectomy.
You asked the Plan to pre-approve a vulvectomy. The Plan denied your request. The Plan says this is a
cosmetic procedure.
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 a vulvectomy. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. Our physician
reviewer found that the record indicates that the enrollee has a redundant right labia minora. The record
contains subjective complaints and no documentation of dermatitis or other such issues that are not responsive
to conservative medical management. The record provided does not establish the medical necessity and
reasonableness, as defined by Medicare rules, of the requested vulvectomy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a vulvectomy have not been met. Therefore, we decided that the Plan does not
have to pre-approve a vulvectomy.