Persius/hicric huggingface dataset:
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 would like reconsideration because the requested IRF care is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare coverage criteria for the requested IRF 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.  Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documentation of a need for an intensive rehabilitation program.  There is not a reasonable expectation that this member 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: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve four (4) additional home health physical therapy visits, for the enrollee.   

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the additional visits are upheld because the enrollee does not meet criteria of medical necessity as the enrollee is no longer confined home.  

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found the additional requested home health therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan. The enrollee has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The enrollee has been approved for additional therapy and can transition to a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration.  

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 four (4) additional home health physical therapy visits, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a left total hip replacement for the enrollee.  

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the clinical documentation provided does not include three months of failed conservative treatment management methodologies prior to surgical treatment.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have three or more of the listed indications for this request. There is no clear and detailed documentation showing the absence of any of the contraindications for this request. Detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. The documentation does not support any distinct structural abnormalities and there is no documentation of a previous left total hip arthroplasty that has failed.    

Additionally, detailed documentation is not evident regarding (the presence or lack of) any active infection of the hip or knee joint or active systemic bacteremia; active skin infection or open wound within the planned surgical site of the hip or knee; progressive neurological disease, etiologic for pain, instability, or disability. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for left total hip replacement is not medically reasonable or necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a left total hip replacement for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on January 17, 2021.  

You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  

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 the anesthesia services is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services coded 99140 provided on January 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.    

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. 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the cytopathology services coded 88120 provided on March 9, 2021.  

You asked the Plan to pay for the cytopathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.  

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 cytopathology services at issue in this appeal were 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 the cytopathology services coded 88120 provided on March 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Q runner.  You asked the Plan to pre-approve a Q runner. You say that you are not able to walk well and need this to shop and be independent. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.   The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a Q runner.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a replacement lower limb prosthesis (L5910, L5620, L5999, L8470, L8440, L5629, L5670, L5645, L5673, L8420, L5301, L5973, L5940, L5637).  You asked the Plan to pre-approve the replacement lower limb prosthesis. You say that the replacement limb is medically necessary. The Plan denied your request. The Plan says only a replacement socket is required.  The Plan follows Medicare rules. Medicare rules say that coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of prosthesis.  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 replacement lower limb prosthesis. Our reviewer says that the replacement limb is not medically necessary. Our physician reviewer found the documentation indicates that the socket needs to be replaced as it is ill-fitting, but that the rest of the prosthesis is functioning and is for a K3 ambulator. The health plan has authorized a replacement socket therefore the requested replacement prosthesis is not 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 replacement lower limb prosthesis have not been met.  Therefore, we decided that the Plan does not have to pre-approve a replacement lower limb prosthesis (L5910, L5620, L5999, L8470, L8440, L5629, L5670, L5645, L5673, L8420, L5301, L5973, L5940, L5637).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric care from January 11, 2022, forward.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that you would like
reconsideration because it is not safe for the member to return home. The Plan denied your request. The Plan
says that the enrollee has reached reasonable expectations for improvement and is medically stable.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 inpatient psychiatric hospital services.
Our reviewer says that based upon review of the records provided, the admission of this member does meet the
criteria for continued acute inpatient mental health treatment for the dates in question of January 11, 2022,
forward. Our physician reviewer found this enrollee did appear to require inpatient mental health treatment
beyond the date in question as she remained delusional. It did appear that active treatment was taking place
beyond the date in question. It did appear that the services were reasonably expected to improve the member's
condition or for the purpose of diagnosis beyond the date in question. It did appear that the records were
supervised and evaluated by a physician.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided
that the Plan has to pre-approve inpatient psychiatric care from January 11, 2022, forward.

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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a transfer to a skilled nursing facility (SNF).  

You asked the Plan to pre-approve the transfer to a SNF. You say that you need to go to a SNF because you are not strong enough to go home yet. You also say that you currently have a feeding tube but are starting to be able to swallow. The Plan denied your request. The Plan says the SNF services you are requesting do 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 the transfer to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.  

We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the transfer to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve a transfer to a skilled nursing facility (SNF).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care provided to the enrollee from
January 13, 2022, forward.

You asked the Plan to pre-approve SNF care. You say that you are now needing extensive rehabilitation to
walk and regain daily movement. You state that you have not fully recuperated, and it is slow going due to
return visits to the hospital, which prevents therapy work. The Plan states every facility is understaffed
preventing you from receiving physical therapy care resulting in your recovery taking longer. The Plan states it
was recommended by your physicians that you continue the therapy care. The Plan denied your request. The
Plan says the stay is not medically necessary based on SNF criteria.

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 there are identifiable skilled nursing service
needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or
therapy services on a daily basis. The enrollee does 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 continuation of SNF care provided to the enrollee from January 13, 2022, forward.
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 requires IRF level of care. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do 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 based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 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 a referral to an out-of-network provider at the in-network rate.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers at the in-network rate.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 35% coinsurance for each Medicare-covered outpatient surgery at an out-of-network outpatient hospital facility.

The request is for services with an out-of-network provider at the in-network rate. If the enrollee chooses to receive services from an out-of-network provider, they will be asked to pay a 35% coinsurance for these services. These services fall within the Medicare-covered outpatient surgery at an out-of-network outpatient hospital facility benefit category. This means that the enrollee will be asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. The Plan has network providers from which the enrollee may receive services at the in-network rate. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider at the in-network rate.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an auricular neurostimulator device (64555, L8679).

You asked the Plan to pre-approve the auricular neurostimulator device. You say that the device is medically necessary. The Plan denied your request. The Plan says this device is non-covered.

The Plan must follow Medicare rules. Medicare rules say that any ear or auricular electrical devices (e.g., DyAnsys) are non-covered by Medicare as electrical acupuncture. 

We looked at the file and Medicare rules. The requested device is considered electrical acupuncture and is non-covered. Based on this information, we decided that Medicare rules for coverage of the auricular neurostimulator device have not been met. Therefore, we decided that the Plan does not have to pre-approve an auricular neurostimulator device (64555, L8679).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prolonged service(s) in the outpatient setting services coded 99354 provided on June 29, 2021.  

You asked the Plan to pay for the prolonged service(s) in the outpatient setting services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.  

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 99354 for the prolonged service(s) in the outpatient setting services is a column II code to column I code 90833. 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 the prolonged service(s) in the outpatient setting services coded 99354 provided on June 29, 2021.