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

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 that you are a 63-year-old male with end stage renal disease on hemodialysis and altered mental status. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from March 18, 2021, to March 21, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that the services could have been provided at a lower level of care.  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 pay for 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 the record shows that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights.  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 pay for the acute inpatient hospital care provided from March 18, 2021, to March 21, 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 power wheelchair.  You asked the Plan to pre-approve a power wheelchair. You say that you need assistance moving around. The Plan denied your request. The Plan says there is no documentation of your ability to safely maneuver a power wheelchair.  The Plan follows Medicare rules. Medicare rules say that a power mobility device is only covered under certain medical indications.   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 power wheelchair. Our physician reviewer found that the documentation does support you have a mobility deficit. You can effectively propel, without cues, a manual wheelchair 200 feet with your arms. The documentation does not reveal that you cannot use an optimally configured manual wheelchair or that you do not have an attendant that can push a manual wheelchair. The documentation does not support that the requested wheelchair will significantly improve your ability to participate in MRADLs in the home over a manual wheelchair. The documentation does not reveal that the requested power wheelchair is 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 a power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts (93978) duplex scan of extracranial arteries (93880) provided August 9, 2021.  You asked the Plan to pay for the diagnostic service. You say that please review medical records clearly supporting CPT 93978 and 93880. The Plan denied your request. The Plan says screening testing is not a Medicare benefit for the diagnoses as listed on the claim and are done for screening purposes.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal, the diagnostic service, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts (93978) duplex scan of extracranial arteries (93880) provided August 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for continuation of SNF services provided from August 9, 2021, through September 7, 2021.   You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services was not medically necessary.  The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide medically necessary and reasonable treatment. No skilled nursing services were provided, and the enrollee did not receive any skilled therapy services. Daily skilled services were not required. As a practical matter, the enrollee did not require the services on an inpatient basis, only in a skilled nursing facility setting.  Services in the nursing facility appear custodial in this case from August 9, 2021, through September 7, 2021.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from August 9, 2021, through September 7, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 that 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 rehab services at a lower level of care. Although further rehab 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 skilled nursing facility.   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 admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical assistant services for a percutaneous implantation of neurostimulator electrodes (63650) provided on August 10, 2021.  You asked the Plan to pay for surgical assistant services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment for surgical assistant services have not been met.  The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current Procedural Terminology (CPT) code 63650. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for surgical assistant services have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services for a percutaneous implantation of neurostimulator electrodes (63650) provided on August 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve facet joint radiofrequency ablations (RFAs).  You asked the Plan to pre-approve facet joint RFAs. You say that the enrollee will significantly benefit from this. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee has met the limit of two radiofrequency sessions per spinal region per rolling 12 months.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions may be covered under certain circumstances, and for each covered spinal region no more than two radiofrequency sessions will be covered per rolling 12 months.   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 facet joint RFAs. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested facet joint injections. Our physician reviewer found the records show that the enrollee has already had two radiofrequency sessions in the cervical spine region since June 2021. This request for another radiofrequency session exceeds the Medicare-allowed frequency for this procedure.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint RFAs have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint radiofrequency ablations (RFAs).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Aimovig injection.  You asked the Plan to pre-approve Aimovig. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aimovig injection.   Benefits for Aimovig may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on August 30, 2021.  You asked the Plan to pay for the CGM supplies. You say that the item was medically necessary. The Plan denied your request. The Plan says there is not a valid proof of delivery.    The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid proof of delivery. No documentation was submitted showing the enrollee received and signed for the supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), provided on August 30, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.  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 that you are an 83-year-old female with fall with right distal femur periprosthetic fracture with open reduction and internal fixation (ORIF), currently in an inpatient rehabilitation facility. While there are identifiable skilled therapy service needs, there are no identifiable skilled nursing service needs. In addition, you do not require skilled nursing or therapy services on a daily basis. In conclusion, you do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for wound care and debridement provided on September 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the wound care and debridement. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for wound care and debridement provided on September 2, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the office visit provided on August 26, 2021.  You asked the Plan to waive the copayment for the office visit. You say that you would like this claim reprocessed and the copayment waived. The Plan denied your request. The Plan says this copayment has processed correctly for the services received.  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 $10 copayment for Primary Care Physician (PCP) office visit.   You have been asked to pay a $10 copayment for the office visit. This service falls within the Primary Care Physician (PCP) office visit 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 the office visit provided on August 26, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a sleep study (95810).  You asked the Plan to pre-approve a sleep study. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says the requested service is not medically necessary as another similar test has been approved and not completed.  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 sleep study. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you do not meet criteria for an attended sleep study. The records do not show that you have a condition such as extreme obesity, heart failure, severe pulmonary disease, or other conditions that would render the home test unsafe or impractical.  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 sleep study have not been met. Therefore, we decided that the Plan does not have to pre-approve a sleep study (95810).
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 Medicare criteria for admission to an IRF.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve total hip arthroplasty.  You asked the Plan to pre-approve total hip arthroplasty. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the record does not show that the enrollee is unable to perform activities of daily living and there is no evidence of conservative measures.  The Plan follows Medicare rules. Medicare rules state that total hip arthroplasty may covered if certain 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 total hip arthroplasty. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested hip surgery. Our physician reviewer found there is no documentation of adequate conservative measures for hip pain. More physical therapy is needed.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of total hip arthroplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve total hip arthroplasty.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (82136, 82139, 82382,82384,82533, 82627, 82965, 84260) provided on December 13, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that you were not told that you needed prior authorization. You also say that you do not have the money to pay it. The Plan denied your request. The Plan says the laboratory services were done at an out-of-network facility and ordered by an out-of-network provider. The Plan also says no physician claim was received, the laboratory services were not urgent/emergent, and the prior authorization was absent.  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 laboratory services (82136, 82139, 82382,82384,82533, 82627, 82965, 84260) provided on December 13, 2020, by an out-of-network (OON) provider.