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

 We decided that the Plan has to pay for the repair of blood vessel lesion rendered on September 8, 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 that procedure code 35231 is inclusive to 20969.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that code 35231 (repair of blood vessel with vein graft, neck) is not separately payable because it is inclusive to code 20969 (free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or great toe); however, there are no active National Comprehensive Coding Initiative (NCCI) edits for these codes. The Plan has not provided any documentation to support that the code is not payable as billed. Therefore, we decided that the Plan has to pay for the repair of blood vessel lesion rendered on September 8, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and accessories.  

You asked the Plan to pre-approve a heavy-duty walker. You say that you need a larger walker. The Plan denied your request. The Plan says the criteria for coverage for the heavy-duty walker have not been met.  

The Plan must follow Medicare rules. Medicare rules say that a heavy-duty walker (E0148, E0149) is covered for beneficiaries who meet coverage criteria for a standard walker and who weigh more than 300 pounds.  

We looked at the file and Medicare rules. In this case, the documentation confirms that you weigh less than 300 pounds. Based on this information, we decided that Medicare rules for coverage of a heavy-duty walker have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty walker (E0149) and accessories.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic exercises (97110), gait training therapy (97116), neuromuscular reeducation (97112), and therapeutic activities (97530) provided on August 23, 2021.  

You asked the Plan to pay for the therapeutic exercises, gait training therapy, neuromuscular reeducation, and therapeutic activities. You say that the services provided were medically necessary. The Plan denied your request. The Plan says that a decision was unable to be made within the 60-day timeframe.  

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 pay for the therapeutic exercises, gait training therapy, neuromuscular reeducation, and therapeutic activities. Our reviewer says that skilled services were not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the documentation does not support that the therapy on this date was specific and effective therapy for the patient's condition. Our reviewer found that the documentation does not support that the unique skills of a professional therapist were required to provide treatment safely and effectively, that the services could be safely and effectively performed only by a therapist, or by or under a therapist on this date. The patient's assessment of function would not be accurate on this date given her feeling ill on this date and the documentation does not support that therapy on this date would be safe and effective. Our physician reviewer also found that the requested services were not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist were note required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic exercises, gait training therapy, neuromuscular reeducation, and therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic exercises (97110), gait training therapy (97116), neuromuscular reeducation (97112), and therapeutic activities (97530) provided on August 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near your baseline and you can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehabilitation services is 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
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 the enrollee is stable and suitable for transfer to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and is currently unstable for 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 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.    

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 long term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the OON MRI. You say that you are in excruciating pain. You say that your doctor needs the MRI as soon as possible in order to diagnose and treat you. You say that you were injured in late December and have been waiting on authorization for treatment. The Plan denied your request. The Plan says there are network MRI providers who are available to see the enrollee.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services to be provided by an out-of-network (OON) provider.
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 enrollee would benefit from IRF care. The Plan denied your request. The Plan says the enrollee would be safely and equally well served with skilled therapy services at an alternative 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 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (72084) provided July 21, 2021.  

You asked the Plan to pay for the chiropractic service. You say that you are asking for a one-time exception to the coverage rules in order to pay for the x-rays taken. Please read the reasons why it was prudent and medically necessary for you to have this x-ray done by a chiropractor. The Plan denied your request. The Plan says this service is not covered when rendered by a chiropractor.  

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.          

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for radiological examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine (72084) provided July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the autograft services provided on June 2, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.  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 20936 is autograft for spine surgery only (includes harvesting the graft); local (e.g., ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure).   We find that CPT code 20936 is a bundled code. When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the autograft services provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on September 1, 2021.  You asked the Plan to pay for the office visit. You say that the office visit was medically necessary. The Plan denied your request. The Plan says the provider did not bill as required by coding regulations. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The records show that the enrollee received osteopathic manipulation during an office visit. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and shall not be reported separately as an evaluation and management service. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the office visit provided on September 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the CardioMEMS device.  You asked the Plan to pre-approve the CardioMEMS device. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says there is not enough evidence that use of device shows improved long-term outcomes as compared to fully optimized medical treatment for heart failure.  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 CardioMEMS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the CardioMEMS device was approved by the Food and Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be considered medically appropriate and necessary in this patient's clinical management.  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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device.
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 medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria. Care can be provided safely in a less intensive setting such as a skilled nursing facility with skilled therapy services.  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 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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a mandibular partial denture for the enrollee.  You asked the Plan to pre-approve a mandibular partial denture. You say that the enrollee lost his partial denture and is unable to eat properly without it. The Plan denied your request. The Plan says that this request exceeds the benefit maximum.  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. The Plan covers a mandibular partial denture once every five plan years.   We looked at the file and Medicare rules. The file indicates the enrollee had a partial lower denture on October 7, 2020, which is less than five years ago. Based on this information, we decided that the Plan's rules for coverage of a mandibular partial denture have not been met. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture 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 the requested IRF care is a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for IRF care 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 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. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for antigen therapy services provided on September 1, 2021.  

You asked the Plan to waive the copayment for the antigen therapy services. You say that you were charged for the injections and you feel that you should not have a copayment for the follow-up visit. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $35 copayment for each specialist visit.   

You have been asked to pay a $35 copayment for the antigen therapy services. The antigen therapy services fall 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 antigen therapy services provided on September 1, 2021.