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

We decided that the Plan does not have to pre-approve surgery to implant a permanent sacral nerve stimulator 
(SNS) (CPT code(s): 64581 and 64590). 
 
You asked the Plan to pre-approve the surgery. You say that the services are necessary. The Plan denied your 
request. The Plan says per the criteria, for this to be covered, you must have urinary urge incontinence, 
urgency-frequency syndrome, and urinary retention, resistance to conventional therapy (documented 
behavioral, pharmacologic and/or surgical corrective surgery), and demonstrate a 50% or greater improvement 
through test stimulation. The Plan states the records provided for the Plan's review does not show that all 
requirements of the criteria have been met. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the surgery have not been met. The notes provided by your doctor 
do not include a covered diagnosis. The notes indicate stress incontinence. The notes do not include voiding 
diaries. The notes do not have a percentage of improvement. Therefore, we decided that the Plan does not have 
to pre-approve surgery to implant a permanent sacral nerve stimulator (SNS) (CPT code(s): 64581 and 64590).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee wouldn't be safe to discharge. You say 
that it is medically necessary for the enrollee to continue care in an IRF. The Plan denied your request. The 
Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the 
services needed in other settings. 
 
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 the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for respiratory failure and pneumonia. The enrollee's medical problems are stable. There are no 
complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, 
including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for 
an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The 
complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient 
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for confusion, metabolic 
encephalopathy, and non-ST elevation myocardial infarction. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient 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 patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our 
physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the programming device evaluation you had at a cardiology clinic on July 2, 2021.
You asked the Plan to waive the copayment for the programming device evaluation. You say that you have never had to pay a copayment for this service in the past. The Plan denied your request. The Plan says you were charged this copayment 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 $40 copayment for physician and practitioner services in a specialist office. You have been asked to pay a $40 copayment for the programming device evaluation. The programming device evaluation falls within the physician and practitioner services in a specialist office 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 programming device evaluation you had at a cardiology clinic on July 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on April 29, 2021. 
 
You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says 
Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to 
the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on April 22, 2021. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing 
facility care provided on April 29, 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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the complete course of care in the inpatient rehabilitation facility has not been completed.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing or skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program 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 the admission 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: 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 SNF care is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says the 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 based on the documentation provided, the enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, can be provided at a lower 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 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 medical services provided to the enrollee on April 8, 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 medical services provided to the enrollee on April
8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional unit of Current Procedural Terminology (CPT) 
86077 provided to the enrollee on June 27, 2021. 
 
You asked the Plan to pay for an additional unit. You say that this should be paid for. The Plan denied your 
request. The Plan says one unit is appropriate for this code. 
 
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 86077 is "Blood bank physician services; difficult cross 
match and/or evaluation of irregular antibody(s), interpretation and written report." 
 
We find that an additional unit of CPT code 86077 is not supported in the medical record. Specifically, the 
Medically Unlikely Edit (MUE) value for this code is 1. This first unit has already been paid. Based on this 
information, we decided that Medicare rules for coverage of an additional unit have not been met. Therefore, 
we decided that the Plan does not have to pay for the additional unit of Current Procedural Terminology (CPT) 
86077 provided to the enrollee on June 27, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on May 19, 2021.  
You asked the Plan to pay for the physical therapy services. You say that the medical records required to 
reprocess the denied claim are attached. The Plan denied your request. The Plan says the records do not support 
the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on May 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from February 17, 2021, to February 23, 2021.
You asked the Plan to pay for the inpatient services. You say that the inclusion of the diagnosis is justified in this case. The Plan denied your request.
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 J96.01, defined as acute respiratory failure, with hypoxemia. 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 inpatient services. Our physician reviewer found that the enrollee was admitted to the acute care hospital for the removal of an infected total knee arthroplasty. The procedure was performed without complication. She was intermittently on room air and nasal oxygen. There was no documentation of respiratory failure with hypoxia. This patient experienced a transient decline in room air pulse oximetry reading. Her oxygenation promptly responded to application of low flow nasal oxygen. The transient, several minute episode of desaturation to 87% is insufficient to report the diagnosis code for Acute respiratory failure with hypoxia. The review has determined that the records did not show that the diagnosis was supported. 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 the inpatient hospital services provided from February 17, 2021, to February 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the scaling in presence of generalization moderate of severe gingival inflammation full mouth, after oral evaluation, (D4346) provided on November 9, 2020.
You asked the Plan to pay an additional amount for the dental service. You say that you only went for a cleaning and an examination. You say that you were advised that light scaling was done too. You also say that you do not remember the scaling and was never advised that it was provided. The Plan denied your request. The Plan says the claim was processed correctly as there is a 50% coinsurance for periodontic services, including scaling.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, there is a 50% coinsurance for periodontic services. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Therefore, we decided that the Plan does not have to pay an additional amount for the scaling in presence of generalization moderate of severe gingival inflammation full mouth, after oral evaluation, (D4346) provided on November 9, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 4, 2021, to May 6, 2021.
You asked the Plan to pay for the acute inpatient hospital care. You say that it is felt that this inpatient stay was medically necessary to monitor the enrollee's condition. The Plan denied your request. The Plan says that denial of inpatient payment was correct as this met criteria for observation care only.
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 the 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 enrollee was a female who was admitted for breakthrough seizures on 5/4/2021. She had hypokalemia on admission which seems to be a chronic problem for her. This was corrected and she was given a maintenance dose of low-dose potassium on discharge. She complained of left-sided chest wall tenderness likely as a result of her fall from the seizure. The review indicates that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient'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 the acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 4, 2021, to May 6, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the catheter change services you received 
in your urologist's office from January 7, 2021, to June 23, 2021. 
 
You asked the Plan to waive the copayments for the catheter change services. You say that you believe that the 
provider doesn't charge a copayment for these services. The Plan denied your request. The Plan says you were 
charged these copayments 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 $30 
copayment per visit for medical care in a specialist's office.  
 
You have been asked to pay a $30 copayment per visit for the catheter change services. This copayment applies 
each time you receive services in a specialist's office, regardless of who performs the services. 
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 copayments for the catheter change services you received in your 
urologist's office from January 7, 2021, to June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.
You asked the Plan to pre-approve the requested LDCT scan. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter. This is a 79 year old enrollee with a documented history of smoking for 63 years. The enrollee does not meet Medicare criteria because beneficiaries must meet all of the following eligibility criteria: Age 55 - 77 years. Therefore, we decided that the Plan does not have to pre-approve a LDCT scan for lung cancer screening.