Persius/hicric huggingface dataset:
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is medically necessary.  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 the enrollee is receiving appropriate care at the present acute care hospital. 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.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for practitioner services provided to the enrollee on July 22, 2021.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The 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 practitioner services provided to the enrollee on July 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a sacroiliac joint radiofrequency ablation provided to the enrollee on June 14, 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 this is considered not medically necessary and investigational.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental and investigational procedure because of the wide range of efficacy reported in the literature. Therefore, the procedure is deemed 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 services have not been met. Therefore, we decided that the Plan does not have to pay for a sacroiliac joint radiofrequency ablation provided to the enrollee on June 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total left shoulder replacement for the enrollee.  You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of a trial and failure of non-surgical treatment.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left total shoulder replacement 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve a total left shoulder replacement for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301).  You asked the Plan to pay for the medical supplies. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says these services are not covered by 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 codes S1015 and S8301 are not supported in the medical record. Specifically, these services both have a status indicator of "I" in the Physician Fee Schedule. As a result, these codes are not valid for Medicare purposes and will not be covered. Based on this information, we decided that Medicare rules for coverage of the medical supplies have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301).
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you are still recovering from surgery. The Plan denied your request. The Plan says your needs can be met at a lower level of care.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you have skilled nursing needs. While you have skilled therapy needs, you do not need skilled therapy on a daily basis. You do not meet the severity of illness or intensity of service criteria for a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.  You asked the Plan to pre-approve these services. 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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has rectal adenocarcinoma with concern for liver metastases. He underwent radiation therapy for metastatic disease in April of 2021. He has undergone CT scanning every three months since. He first underwent treatment in 2018. The National Comprehensive Cancer Network (NCCN) guidelines recommend a CT scan for stage IV rectal cancer every three to six months for the first two years. The most recent CT scan of the abdomen/pelvis was on August 10, 2021. The repeat CT is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve a computed tomography (CT) scan of the jaw/face.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the records show that you have temporomandibular (TMJ) disease and had recent surgery, but your new jaw position doesn't align. You last had imaging several years ago. The MRI is being requested for surgical planning. Given that the physician is intended to surgically correct your misalignment of the jaw, the CT scan is reasonable and medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve a computed tomography (CT) scan of the jaw/face.

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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic services provided to the enrollee on October 1, 2020 and billed under code 97110.  You asked the Plan to pay for this claim. You say that these services should be paid by the Plan. The Plan denied your request. The Plan says there is a more code for this service which should have been G0157. The Plan notes that multiple attempts were made to contact the provider for additional information or correction.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, there is a more appropriate code for the billing of this service on Medicare claims. Medicare rules for coverage of this claim have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic services provided to the enrollee on October 1, 2020 and billed under code 97110.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for eyeglasses provided on July 31, 2021.  You asked the Plan to pay for eyeglasses. The Plan denied your request. The Plan says the provider must be a network provider to receive these benefits.  Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when provided by a network optical provider.  We looked at the file and the Plan's rules. The file shows that the eyeglasses were not provided by a network optical provider. Based on this information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for eyeglasses provided on July 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do require physical therapy and occupational therapy services but based on the medical records provided you not require an intensive inpatient rehabilitation therapy program. Medically necessary services can be provided in a different level of care.  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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance transport rendered on March 28, 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 claim was not billed correctly.  The Plan must follow Medicare rules. Medicare rules say that modifier -QL must be billed when a patient is pronounced dead after an ambulance is called.  We looked at the file and Medicare rules. The file shows that the patient was pronounced dead after the ambulance was called and the services were not billed with the required -QL modifier. 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 ambulance transport rendered on March 28, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health services.  You asked the Plan to pre-approve the services. You say that you are alone and would benefit from further assistance. The Plan denied your request. The Plan says your primary care physician says that you do not need these services.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the documentation does not support that you require in-home skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The documentation does not support that you are homebound. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Services can be received on an outpatient 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-emergency transportation: wheelchair van (A0130) greater than 50 miles.

You asked the Plan to pre-approve the routine transportation. You say that the enrollee requires transportation to an appointment. The Plan denied your request. The Plan says the requested trip exceeds the 50-mile limit.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine transportation when each one-way trip is within a 50-mile limit.

We looked at your request, the records in the case file, and the rules. The requested trip in this case exceeds 50 miles. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve the non-emergency transportation: wheelchair van (A0130) greater than 50 miles.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided on June 3, 2021.

You asked the Plan to pay for out of network providers. . You say that these services should be covered by the Plan. The Plan denied your request. The Plan says you did not have prior authorization of out of network care.

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 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 out of network physician services provided on June 3, 2021.
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for the non-emergent ambulance transport (A0428) and ground mileage (A0425) from a skilled nursing facility to a physician's office and back provided on June 28, 2021.  You asked the Plan to pay for the ambulance services. You say that the non-emergent ambulance transport was medically necessary. The Plan denied your request. The Plan says that the transportation 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 the ambulance services. Our reviewer says that the non-emergency ambulance services are considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical records provided there is documentation that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on June 28, 2021, as they were documented as having severe weakness, pain, contractures, decubitus ulcers, inability to ambulate or stand and inability to sit in a wheelchair. The reviewer found that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The reviewer also found that based on the medical records provided the ambulance transport on June 28, 2021, was medically reasonable and necessary for the enrollee.  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 ambulance services have been met. Specifically, the file shows that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for the enrollee on the date of service. Therefore, we decided that the Plan has to pay for the non-emergent ambulance transport (A0428) and ground mileage (A0425) from a skilled nursing facility to a physician's office and back provided on June 28, 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the X-ray services (71045) provided on April 30, 2021.  You asked the Plan to pay for the X-ray services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says they are missing required information that supports the service as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that claims or claim lines that have been determined to be exact duplicates of another claim or claim are line are denied.  We find that payment for an additional CPT code billed as 71045 on April 30, 2021, is not supported in the medical record. Specifically, there is no documentation provided that supports that two units of 71045 were performed on April 30, 2021. Based on this information, we decided that Medicare rules for coverage of the X-ray services have not been met. Therefore, we decided that the Plan does not have to pay for the X-ray services (71045) provided on April 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  You asked the Plan to pre-approve these services. 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. Medicare rules say that RFA is covered when specific criteria are met.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you have had two prior sessions per spinal region in the past 12 months. The Medicare criteria allow only two RFA sessions per rolling 12 months. Repeat RFA is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).