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

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on March 29, 2021.

You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. You say that physician's orders were submitted for review as patient required ground ambulance transport by stretcher due to Coronavirus (COVID-19), bed confined, and unable to sit. The Plan denied your request. The Plan says the ambulance services are not covered.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 

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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance services were not medically necessary. Our physician reviewer found that the enrollee is a 79-year-old female who was transported via ambulance to her home after being treated for Coronavirus (COVID-19) infection, shortness of breath, and weakness. She was given continued oxygen supplementation and transported without incident. The documentation does not support that other means of transport (such as stretcher van) were contraindicated for this enrollee. The documentation does not support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport.

There was no documentation of the enrollee having hypoxia without oxygen. The documentation does not support that the ambulance transport on March 29, 2021 was medically reasonable and necessary for the enrollee. The enrollee was coming home from the hospital and was stable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on March 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the custom abutment includes placement (D6057) and abutment supported porcelain fused to metal crown (D6058).
You asked the Plan to pre-approve the custom abutment includes placement and abutment supported porcelain fused to metal crown. You say that the service is medically necessary. The Plan denied your request. The Plan says the requested service is not a covered benefit.
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 pre-approve the
custom abutment includes placement (D6057) and abutment supported porcelain fused to metal crown (D6058).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan, thorax, diagnostic; without contrast material (CPT code 71250).

You asked the Plan to pre-approve the CT scan. You say that you are concerned that an x-ray will not show the changes in your lung and the CT testing could find something sooner than later. The Plan denied your request. The Plan says your doctor told the Plan that you have had abnormalities on another picture of your chest. The Plan states this CT should be used to help your doctor determine the best treatment plan for you. The Plan state your doctor did not tell the Plan that this is the reason you need this test.

The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CT scan. Our physician reviewer found the review indicates that although short-term follow up in three (3) months was recommended based on the 2017 guidelines from the Fleischner Society for Management of Incidentally Detected Pulmonary Nodules, this nodule that is less than 6 mm should be followed with CT in April 2022. The review has determined that the requested CT scan is not medically reasonable or 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 the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan, thorax, diagnostic; without contrast material (CPT code 71250).
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 have no one to help you at home. You need inpatient rehabilitation to return to your prior level of function and live your life safely. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You would likely benefit from additional care and therapy, but these services can safely be provided in a skilled nursing facility.

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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic CGM system (CPT code K0554), for the enrollee.
You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the CGM is not covered for enrollee's not on insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic CGM system (CPT code K0554), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's needs can be met in a less intensive setting.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that 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.

While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (14302, 14301, 15730) provided on February 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes are 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 14302 is "Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)". The CPT Code Manual definition of code 14301 is "Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm". The CPT Code Manual definition of code 15730 is "Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)".
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 use of codes 14302, 14301, and 15730, is not supported by the records provided. Our reviewer found that the medical records provided do not include sufficient documentation to validate that an "adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof", was performed on February 2, 2021. Therefore, code 14302 cannot be verified. The medical records provided do not include sufficient documentation to validate that an "adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm" was performed. Therefore, this code 14301 cannot be verified. The medical documentation submitted does not include sufficient documentation to validate a "midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s)", was performed on February 2, 2021. Therefore, code 157300 cannot be verified. 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 the services (14302, 14301, 15730) provided on February 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on April 7, 2021.
You asked the Plan to pay for physical therapy services. You say that the records show the billed code is valid according to the services provided. You say that the medical records should be reviewed, and the claim should be reconsidered for reimbursement. The Plan denied your request. The Plan says the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say services of a therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. Medicare rules also say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of physical therapy services have not been met. Specifically, the billing provider is a physician assistant, which is a non-physician practitioner, and not a licensed therapist. As such, PT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided on April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the occupational therapy evaluation provided on March 24, 2021.
You asked the Plan to pay for the occupational therapy evaluation. You say that the claim denied incorrectly without appropriate review of the medical records. You say that the records should be thoroughly reviewed, and the claim should be reprocessed toward payment. The Plan denied your request. The Plan says the billed service is not supported.
The Plan must follow Medicare rules. Medicare rules say services of a therapist billed as services incident to a physician/non-physician practitioner's service must meet all incident requirements. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the occupational therapy evaluation have not been met. Specifically, the billing provider is a physician assistant, which is a non-physician practitioner, and not a licensed therapist. As such, OT services cannot be paid incident to this provider's professional services. Additionally, the record does not include the rendering providers credentials, so we are unable to verify the billed services. Therefore, we decided that the Plan does not have to pay for the occupational therapy evaluation provided on March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient services.

You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee had a broken neck and nose and was in no condition for discharge. The Plan denied your request. The Plan says that this is considered custodial care and is not a covered benefit.

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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency department with a history of fall. The CT scan showed type 2 dens fracture, and post subluxation of C1 and C2, with acute ankle fracture. She was admitted to the hospital due to not being stable to transfer. Neurosurgery recommended nonsurgical treatment with neck collar for 6 weeks. However, as the enrollee had dementia and kept pulling off the neck brace, discharge to a lower level of care was not appropriate. Therefore, it was expected that the enrollee would require hospital services that would likely cross two midnights until more stable and more appropriate supervision was arranged. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve continued inpatient services.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's medical needs are being met in the current acute 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. 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 he 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for respiratory failure, Coronavirus infection, and rib fractures after a fall. He is now medically stable with no complex nursing or rehabilitation needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the clinical information provided supports the need for SNF care. The Plan denied your request. The Plan says that daily physical therapy or occupational therapy is not medically necessary to establish a maintenance program, to prevent deterioration, or to preserve current physical capabilities for this member.

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 the criteria for coverage of SNF care have been met. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below her baseline. Records do not show that the enrollee has reached a new, lower, baseline of function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition. 

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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.