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

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that SNF care is medically necessary. You say that the enrollee is not at baseline level of function. The Plan denied your request. The Plan says the enrollee does not meet the requirements for coverage of SNF care. The Plan says that the services required can safely be received at a different setting.  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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and had clear lungs. The enrollee received physical therapy and occupational therapy. The enrollee was at a standby assist to contact guard assist level for functional mobility, including gait to 65 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the panel testing services provided on July 8, 2021.

You asked the Plan to pay for the testing services. You say that the testing is more reliable than the common point of care treatment. The Plan denied your request. The Plan says the testing is not a covered benefit for the diagnosis listed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 

The file shows that a urinary tract infection panel testing was provided. We looked at the file and the rules. In this case, there are insufficient medical records to show that the testing was necessary above the standard of care testing. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing services provided on July 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure codes 36215 and 75710)
provided to the enrollee on June 16, 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 denied codes remain not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of the denied codes is:
CPT 36215:
Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a
vascular family
CPT 75710:
Angiography, extremity, unilateral, radiological supervision and interpretation
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 the procedure report does not include
documentation of selective catheter placement, arterial system (CPT 36215). Therefore this procedure cannot
be confirmed as performed. The procedure report does not include documentation of angiography extremity
with radiological supervision and interpretation. (CPT 75710).
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 surgical services (procedure codes 36215 and 75710) provided to the enrollee on June 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for a new replacement BiPAP (Bilevel Positive
Airway Pressure) machine.
You asked the Plan to provide coverage for this equipment. You say that this equipment was recalled and
should be replaced by the Plan. The Plan denied your request. The Plan says Medicare coverage criteria for full
replacement are not met. We overturned the Plans denial. The Plan requested a reopen and stated that this
equipment was less than five years old. The recall of the equipment should have been handled between you and
the provider to determine if the equipment simply needed adjustment due to the recall or replacement as the
decision of the provider. While it is understood the provider could not give a specific timeframe for repair or
replacement, there was no indication that a workaround other than new equipment was attempted.
The Plan is correct in this case. The Plan must follow Medicare rules. The rules say Medicare covers
equipment only when it is reasonable and necessary. If equipment serves the same purpose as equipment
already available to an enrollee, it is not considered reasonable and necessary.
Equipment less than five years old is only replaced completely for new equipment when the current equipment
is not repairable or when your medical condition has changed, and the equipment is not appropriate for your
use. The file shows the provider issued a voluntary recall for equipment adjustment. There is no indication this
equipment was not working. There is no indication that the provider refused to provide you with alternative
equipment to use while they work with adjustment of your equipment. Your medial condition did not require
full replacement or new equipment. Therefore, we decided that the Plan does not have to provide coverage for
a new replacement BiPAP (Bilevel Positive Airway Pressure) machine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the otolaryngology visit and binocular microscopy test you had on June 29, 2021.

You asked the Plan to waive the copayments for the otolaryngology visit and binocular microscopy test. You say that you shouldn't have a copayment to look in your ears. You said that you had this service in the past and didn't have a copayment. You said that this should be treated as a routine hearing exam. The Plan denied your request. The Plan says you were charged this cost sharing correctly. The Plan says that for the binocular microscopy, because the allowed amount for this service ($27.59) is less than your copayment obligation for this service, you are responsible for the full allowed 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 $40 copayment for visits with a specialist. 

You have been asked to pay a $40 copayment for the otolaryngology visit and a $30 copayment for the binocular microscopy test. According to the billing records, you did not have a routine hearing exam, so it would not be appropriate for the $0 hearing exam cost sharing to apply here. The billing records show that you had an office visit with a specialist and a binocular microscopy, which is a diagnostic procedure. This means that you have been asked to pay the correct amounts 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 copayments for the otolaryngology visit and binocular microscopy test you had on June 29, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health occupational therapy visits.  You asked the Plan to pre-approve home health care. You say that you are unable to bathe or drive The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not meet the criteria for home health 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 home health care. Our reviewer says that you do not meet the criteria for the requested home health care. Our physician reviewer found you do not have documented ongoing home health occupational therapy needs. You appear to be functioning well using compensatory mechanisms and your left upper extremity. Documentation does not show your current right upper extremity weight-bearing status or a lack of caregiver availability.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pre-approve home health occupational therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on October 1, 2020.
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 requires modifier 26.
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 the denied codes is: CPT 95861: Needle electromyography; 2 extremities with or without related paraspinal areas CPT 95868: Needle electromyography; cranial nerve supplied muscles, bilateral
CPT 95940: Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) CPT 95937: Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method CPT 95938: Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs CPT 95939: Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs CPT 95927: Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head 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 per the CMS guidelines, with relation to services furnished in a facility POS (place of service) 19.21,22,23,24,26,31,34,51,52,55,56,57,61, any services that are provided in a facility POS and that are subject to the PC/TC concept or that have both a Professional Component and a Technical Component will reimburse the interpreting physician or other qualified health care professional only PC as the facility is reimbursed for the TC of the service. Arrangements would be made with the facility, for reimbursement of TC. 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 neurophysiology services provided to the enrollee on October 1, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continuation of skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan denied your request. The Plan says that based on Medicare guidelines, your request for approval of continued admission in a skilled nursing facility does not meet the requirements for approval.
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 continuation of SNF care is medically necessary. Our physician reviewer found that you do have documented skilled nursing needs. You do have documented skilled therapy needs. You have been experiencing hypotension and orthostasis, falls, decreased functionality, and increased behavioral issues. These issues have been attributed, at least in part, to medication changes. The medications are being adjusted. Ongoing vital sign monitoring, mobility supervision and rehabilitative therapies are required to establish a maintenance program and/or to prevent deterioration of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve continuation of SNF care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on May 18, 2021, through May 20, 2021.  You asked the Plan to waive the copayment for the inpatient hospital care. You say that you should not have to pay a copay. The Plan denied your request. The Plan says the cost share was applied correctly.  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 $225 copayment each day one through seven for inpatient hospital care.   You have been asked to pay a $225 copayment each day one through seven for the inpatient hospital care. This service falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan ($225 x 2 days = $450). 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 inpatient hospital care provided on May 18, 2021, through May 20, 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 you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital with Coronavirus pneumonia and acute respiratory failure. She does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available at the current facility. The LTACH services are 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 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: SNF
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) care provided on June 24, 2021,
through July 23, 2021.
You asked the Plan to pay for the SNF care. You say that the service was medically necessary. The Plan denied
your request. The Plan says that the service was not medically necessary.
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 did not provide us with a copy of the NOMNC or medical records in
order to determine medical necessity of the service. Therefore, we decided that the Plan has to pay for the
skilled nursing facility (SNF) care provided on June 24, 2021, through July 23, 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 the MyoPro powered arm brace for the enrollee.  You asked the Plan to pre-approve the brace. You say that this is medically necessary. The Plan denied your request. The Plan says experimental and investigational devices are not covered by Medicare.  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 brace. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that at this time, the requested robotic orthosis is not proven to be more beneficial for treatment of the enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy such as conventional treatments for post stroke hemiparesis therapy including constraint induced movement therapy, conventional muscle strengthening, and botox for spasticity if needed. The requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or  to improve the functioning of a malformed body member. The MyoPro is not known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is insufficient evidence in the literature that the MyoPro Orthosis will improve the long term outcomes for this enrollee, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the literature that this device will increase  participation in bimanual activities.  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 brace have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro powered arm brace for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for physical therapy provided on August 11, 2021.  You asked the Plan to waive the deductible for physical therapy. You say that you were billed for a service you didn't receive. The Plan denied your request. The Plan says the deductible applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible that applies to outpatient therapy.      The item or service you asked the Plan to waive the deductible for falls within the "Outpatient rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which applies to outpatient therapy. This cost sharing is a contractual obligation that had not been met at the time physical therapy was received on August 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for physical therapy provided on August 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the volvulus reduction provided on September 28, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says this procedure is inclusive to the main procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
In this case, the CPT Code Manual definition of code 44050 is reduction of volvulus, intussusception, internal hernia, by laparotomy. The file shows that code 4450 was billed with an -XS modifier. We find that code 44050 is not supported in the medical records provided.
The records show that the volvulus reduction was performed during a right colectomy procedure. Modifier XS is used appropriately for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs. The medical records provided do not show that the service billed with the -XS modifier is a distinct procedural service. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have not been met. Therefore, we decided that the Plan does not have to pay for the volvulus reduction provided on September 28, 2020.