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

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is subject to the coverage criteria listed 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 a spinal cord stimulator. Our reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer found that the medical records do not show that the patient has an approved diagnosis for the device. The use of the device for a non-approved diagnosis is experimental. Therefore, the criteria for coverage have not been met. 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 spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
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 does not meet criteria.
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 appears to be improving but is not yet stable. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed, the fever is addressed and the enrollee is more 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 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve five home health physical therapy visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of a need for the knowledge, skills, and judgement of a physical therapist for care.
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 visits. Our reviewer says that the
requested visits are not medically reasonable or necessary. Our physician reviewer found based on the medical
records provided, there is no documentation that additional skilled therapy services are required to effectively
provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a
maintenance program to maintain your level of function and/or prevent deterioration. You have had physical
therapy on a home exercise program; as of 12/10/21 you were walking 100 feet with a rolling walker with
stand-by assistance. You were stand-by assist for transfers. Further utilization of the home program appears
appropriate at this point.
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 visits have not been met. Therefore, we decided that the Plan does not have
to pre-approve five home health physical therapy visits
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 the enrollee did not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care at the time of discharge from the hospital. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 6, 2021, to June 8, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with . 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 services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the enrollee is a 61 year old male with multiple sclerosis who presented to the emergency department on June 6, 2021 with chills, fever, and fatigue Sepsis 1 criteria met with leukocytosis and fever. SOFA score is 0 and urine culture is positive. The review indicates that services were not billed with the appropriate DRG and diagnosis codes in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 6, 2021, to June 8, 2021.
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 based on the medical records provided this enrollee does not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in a long-term care facility on a part time basis appear appropriate in this case. 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 pay for imaging services (procedure code 70540) provided to the enrollee on August 8, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this is an unbundled service.
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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 70540) provided to the enrollee on August 8, 2021.
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 does not meet criteria.
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 appears to be improving and should only require short-term additional acute care that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.
Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 need an IRF admission. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF admission does not meet the requirements for approval.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.
Our physician reviewer found 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: 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 does not meet criteria.

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 appears to be improving and should only require short-term additional acute care that can be completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation services.
You asked the Plan to pre-approve radiofrequency ablation services. You say that this service is medically
necessary for your condition. The Plan denied your request. The Plan says the maximum number of
radiofrequency ablation services has already been hit.
The Plan must follow Medicare rules. Medicare rules say that no more than two radiofrequency sessions will
be reimbursed per rolling 12 months.
We looked at the file and Medicare rules. You last received 2 radiofrequency ablation procedures in June 2021.
Therefore, coverage for the requested service has currently been exhausted at this time. Based on this
information, we decided that Medicare rules for coverage of radiofrequency ablation services have not been
met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 medical record does not indicate that the enrollee requires services that she is not
currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are
not satisfied. The requested service cannot be recommended.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on May 6, 2021.
You asked the Plan to pay for an ankle-foot orthosis (L1971) provided to the enrollee on May 6, 2021.. You say that this claim should be reprocessed and paid. The Plan denied your request. The Plan says the enrollee had no prior relationship with the prescribing physician.
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 an ankle-foot orthosis (L1971) provided to the enrollee on May 6, 2021.. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a physical examination of the ankle and foot would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthosis was medically reasonable and necessary in this case, as there is no documentation of a credible physical examination of the ankle and foot. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an ankle-foot orthosis (L1971) provided to the enrollee on May 6, 2021. have not been met. Therefore, we decided that the Plan does not have to pay for an ankle-foot orthosis (L1971) provided to the enrollee on May 6, 2021.
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 does not meet criteria.
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 has had a prolonged hospital course and continues to receive acute care services that have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH 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 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 pay for an electrocardiogram (EKG) provided to the enrollee on April 25, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the procedure was not billed with the correct modifiers to correctly meet guidance for separate reimbursement.
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 93010 is "Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only." 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 services at issue in this case were not supported by the medical records. Our reviewer found there is no documentation of an emergency room visit, and an EKG was submitted for review. Per the Medicare guidelines, an EKG can be reported on the same day if reported correctly.
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 an electrocardiogram (EKG) provided to the enrollee on April 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revita skin substitute.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there are insufficient studies available showing the efficacy of placenta derived skin substitutes for the healing of chronic wounds.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Revita skin substitute is currently being investigated in ongoing trials. There are insufficient data available showing the efficacy of placenta derived skin substitutes for the healing of chronic wounds. 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 Revita skin substitute