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 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office consultation (99241), pathology examination (88305), and biopsy of the mouth (40808) provided on July 13, 2021, and July 28, 2021, by a Medicare opt-out provider.  You asked the Plan to pay for the office consultation, pathology examination, and biopsy of the mouth. You say that the biopsy was done to make sure it was not cancerous. You also say that you would like these services to be covered by the Plan. The Plan denied your request. The Plan says these services were rendered by a provider who has opted out of Medicare.    The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office consultation (99241), pathology examination (88305), and biopsy of the mouth (40808) provided on July 13, 2021, and July 28, 2021, by a Medicare opt-out provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve home health skilled nursing and home health aide services.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee's conditions are chronic, education has been provided, and bathing needs can be met by family or a caregiver.  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.  The file shows that 5 home health skilled nursing, and 8 home health aide visits were requested. 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 requested services. Our physician reviewer found that in this case, the documentation doesn't support that the enrollee requires additional skilled nursing services to provide treatment that is medically necessary. She does not require additional skilled nursing services to provide treatment to improve her condition, or to perform a maintenance program to maintain her condition or prevent deterioration. She has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She requires custodial care that can be provided by family or an unskilled person. Therefore, the requested home health services are 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health skilled nursing and home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics.  You asked the Plan to pre-approve foot orthotics. You say that the enrollee has right foot bunion, lesser toe deformities, and chronic painful callus. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and re-cement or re-bond crown (D2920) provided September 2, 2021.  You asked the Plan to pay for the limited oral exam and re-cement crown. You say that this was a straightforward procedure and should be covered by your plan. The Plan denied your request. The Plan says these services are not covered under your benefits.  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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) and re-cement or re-bond crown (D2920) provided September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve PCP services (CPT code 99213).  You asked the Plan to pre-approve the services. You say that you have seen this physician for years and need this to be covered. The Plan denied your request. The Plan says this provider is not contracting as a PCP.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. 
You must choose a network PCP to provide and oversee your medical care. Although the requested provider is a network provider, they are not contracted as a network PCP. Therefore, we decided that the Plan does not have to pre-approve PCP services (CPT code 99213).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 4 additional physical therapy visits.  You asked the Plan to pre-approve physical therapy. You say that more visits are needed to achieve the enrollee's goals. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee is able to exercise on her own and would exhibit further improvement by continuing a home exercise program.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 physical therapy.  Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee has been treated with outpatient therapy and should be independent with a home exercise program. There is no documentation of a recent injury or decline in function. The additional therapy services are not an appropriate duration and frequency for treatment of the enrollee's medical condition and therefore are 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 physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional physical therapy visits.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department services coded 99285 provided on May 14, 2021.  You asked the Plan to pay for the emergency department 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 supported by the documentation.  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 99285 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.   We find that CPT code 99285 is supported in the medical record. Specifically, this code was billed with a diagnosis code of Z01.810 (Encounter for preprocedural cardiovascular exam). This code may only be used as the first-listed or primary diagnosis. Since this code was not billed as the first-listed/primary diagnosis code, rules for payment have not been met. Based on this information, we decided that Medicare rules for coverage of the emergency department services have been met. Therefore, we decided that the Plan does not have to pay for the emergency department services coded 99285 provided on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on June 4, 2021.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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. Review of the file shows that no medical records were provided to support that the genetic testing at issue in this appeal was requested not 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 genetic testing provided on June 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99100, 99140) provided May 25, 2021.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the codes 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.
We find that CPT codes 99100 and 99140 are not supported in the medical record. Specifically, per the
National Physician Fee Schedule, the billed codes have a status of "B". Payment for these codes is always
bundled with another code. Based on this information, we decided that Medicare rules for coverage of the
anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia
services (99100, 99140) provided May 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for an inpatient hospital admission for a total right reverse shoulder arthroplasty.  You asked the Plan to pay for acute inpatient hospital care. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support an expectation of a requirement for a greater than 2 midnight stay.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the record does not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The enrollee is medically stable and has been provided medical clearance to undergo this elective procedure. The planned procedure listed under CPT code 23472 is not listed on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient hospital admission for a total right reverse shoulder arthroplasty.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the Mohs micrographic technique (17311) provided on March 22, 2021.  You asked the Plan to pay for the Mohs micrographic technique. You say that CPT 17311 is a primary code for the first stage of a Mohs micrographic technique. The Plan denied your request. The Plan says that records show an independent laboratory rendered service code 88305 26 and 88305 TC on the same date of service.  The Plan must follow Medicare rules. Medicare rules say that  he Mohs micrographic surgery CPT codes include skin biopsy and excision services (CPT codes 11102-11107, 11600-11646, and 17260-17286) and pathology services (88300-88309, 88329-88332).  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Mohs micrographic technique have been met. Specifically, CPT code 17311 is the primary Mohs surgery code and should be paid. CPT code 17311 includes the pathology service. Additionally, the record indicates that the pathology service that was paid was billed by a different physician. In this case, the Plan's denial is not appropriate. Therefore, we decided that the Plan has to pay for the Mohs micrographic technique (17311) provided on March 22, 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: Favorable

 We decided that the Plan has to pre-approve out of network (OON) dialysis services.  You asked the Plan to pre-approve the OON dialysis services. You say that you would like to continue treatment with the OON provider because it is close to your house and because this has bene the provider supplying you care since you began treatment. The Plan denied your request. The Plan says that there are network providers who are able to supply the care needed.  Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   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 OON dialysis services. Our reviewer says that the criteria for coverage of OON care have been met. Our physician reviewer found access to care and continuity of care are important in the management of hemodialysis patients. The importance increases with the number of medical problems and age of the enrollee. Changing providers and making access to care will be detrimental to the care of this enrollee. Our physician reviewer found that the quality of this enrollee's care would be compromised by changing units. Our physician reviewer found that the best practice medicine would be for enrollee to stay at current unit.  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 OON dialysis services have been met. Therefore, we decided that the Plan has to pre-approve out of network (OON) dialysis services.   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: Testing
Decision: Favorable

 We decided that the Plan has to pay for the needle electromyography (95886) and nerve conduction study (95910) provided on May 25, 2021.  You asked the Plan to pay for the needle electromyography and nerve conduction study. You say that this claim has been billed with a valid diagnosis. The Plan denied your request. The Plan says that the diagnosis codes billed are not consistent with Medicare billing rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that these services will only be covered when billed with diagnoses listed in the appropriate Local Coverage Article.  We find that CPT code 95910 and 95886 have been billed with diagnoses that are valid for Medicare billing purposes. In this case the Plan has denied payment stating that the billed diagnoses of M25.571 and M25.572 are not valid for coverage based on Local Coverage Determination (LCD): Nerve Conduction Studies and Electromyography (L35081). This LCD is not valid for the enrollee's state of South Carolina. It is incorrect to use this LCD as it has no jurisdiction for South Carolina. Based on the more appropriate Local Coverage Article A56619, the billed diagnoses are eligible for payment. Based on this information, we decided that Medicare rules for coverage of the needle electromyography and nerve conduction study have been met. Therefore, we decided that the Plan has to pay for the needle electromyography (95886) and nerve conduction study (95910) provided on May 25, 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: 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 the SNF services. You say that the medical records provided support the need for continued SNF care. The Plan denied your request. The Plan says continued SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The medical records provided show that the enrollee does not require services on an inpatient basis, only in a SNF setting. Custodial care in a long-term care facility appears appropriate at this time. 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that the medical records provided support the need for
IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
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 weakness. 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.