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 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 cough and shortness of breath after recent coronavirus infection. 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.
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 step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not support that the required drugs would be contraindicated or less effective; therefore, Euflexxa is 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for a shoe modification (L3649) provided on March 11, 2021.
You asked the Plan to pay for a shoe modification. You say that this item is an integral part of a brace. The Plan denied your request. The Plan says that this is only covered for enrollees with diabetes.
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 rules also say that shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), are covered if they are an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. 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 has stated that the item at issue is only covered for beneficiaries with diabetes, but it is also covered when it is an integral part of a brace. The records in the file indicate that this item was ordered for the proper functioning of the brace. The Plan has not provided information supporting that this is not the case. Therefore, we decided that the Plan has to pay for a shoe modification (L3649) provided on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 28, 2020.
You asked the Plan to pay for the lab services. You say that you have no knowledge of the enrollee's coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says the billed codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided lists the place of service as an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (36222) provided on March 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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. 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 use of code 36222 is not supported by the records provided. Our reviewer found that this code was billed with modifier 59. The documentation does not support a distinct procedure, and would be inclusive to primary service. The documentation does not support a different procedure or surgery, different anatomical site or separate injury.
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 the services (36222) provided on March 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an intermittent limb compression device (E0675) and
pneumatic appliance (E0673) provided on September 4, 2020.
You asked the Plan to pay for an intermittent limb compression device and pneumatic appliance. You say that
the requested items were a medical necessity for the enrollee. The Plan denied your request. The Plan says
pneumatic compression devices are not covered by Medicare for prevention of deep venous thrombosis.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically
necessary for the treatment of lymphedema and/or for the treatment of chronic venous insufficiency with
venous stasis ulcers.
The file does not show that the enrollee has lymphedema and/or chronic venous insufficiency with venous
stasis ulcers. Therefore, we decided that the Plan does not have to pay for an intermittent limb compression
device (E0675) and pneumatic appliance (E0673) provided on September 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 additional PT visits. 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 that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have 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. You have been instructed in 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 your 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for intermittent limb compression device.
You asked the Plan to pay for intermittent limb compression device. You say that the equipment was prescribed by the doctor for use during their surgery. You are not contracted with the facility or the prescribing physician and do not receive payment from either provider. The Plan denied your request. The Plan says pneumatic compression devices are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery. The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers. In this case, the enrollee used the equipment in the facility during and/or after surgery. Payment for this service would have been included under the facility claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not have to pay for intermittent limb compression device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is 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 considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee requires services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sacroiliac joint injection procedure you had at an outpatient hospital facility on February 11, 2021.

You asked the Plan to waive the copayment for the sacroiliac joint injection procedure. You say that this injection should not be considered surgery and the charge is excessive. 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 $350 copayment for surgery or other services provided at an outpatient hospital.

You have been asked to pay a $350 copayment for the sacroiliac joint injection procedure. This copayment applies to all procedures at an outpatient hospital facility. 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 sacroiliac joint injection procedure you had at an outpatient hospital facility on February 11, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that 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 based on the medical records provided there is no documentation that you require the 
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled 
nursing facility level appears to be appropriate in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 pay for the physical therapy services (G0151) provided on December 2, 2019.
You asked the Plan to pay for the physical therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was not billed on the appropriate claim form for institutional providers.
The Plan must follow Medicare rules. Medicare rules say that the services of a 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 record indicates that this claim was billed by an NPP. The record also shows that the services were rendered by a PTA. The services of a PTA cannot be billed by a physician or NPP. Therefore, we decided that the Plan does not have to pay for the physical therapy services (G0151) provided on December 2, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you need additional 
transportation trips for your medical appointments. The Plan denied your request. The Plan says the benefit for 
routine transportation has been exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers a maximum of 24 one-way trips per year. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
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 needs can be safely met in a lower level of care.
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
the requested admission is not medically necessary. Our physician reviewer found here are no identifiable
skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do
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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block for the enrollee.
You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your
request. The Plan says medical studies have not proven that this device is helpful for treatment of the health
problem.
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 block. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found genicular nerve blocks and genicular nerve ablation are considered investigational and not medically
necessary for the treatment of chronic knee pain, including, but not limited to any of the following:
degenerative joint disease; osteoarthritis of the knee; as a treatment prior to knee replacement; as a treatment
following knee replacement; or as a treatment for individuals who are not candidates for knee replacement
surgery. The review has determined that the genicular nerve blocks are considered experimental/investigational
in nature. The requested genicular nerve blocks are not reasonable and 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 block have not been met. Therefore, we decided that the Plan does not have
to pre-approve a genicular nerve block for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on December 12, 2019.
You asked the Plan to pay for the services provided. You say that most of the requested services were not available on an outpatient basis secondary to the pandemic. The Plan denied your request. The Plan says an appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 92526 is 1. The MAI value for this code is 2. You billed 3 units of this code, exceeding the MUE.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that that CPT ode 97110 is separately payable when billed with code 92526. However, the submitted claim does hot show that code 97110 was billed with an appropriate modifier. Based on this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the therapy services provided on December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a physician who has furnished a consultation or treats an enrollee for a specific medical problem.
We looked at the file and Medicare rules. The file does not contain documentation of an established relationship between the enrollee and the ordering provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office services provided on May 28, 2021, by an OON
provider.
You asked the Plan to pay for office services. You say that you were switching to a preferred provider
organization (PPO) starting June 1, 2021, and were told this appointment would be fine. The Plan denied your
request. The Plan says the denial of payment for these services is correct, because this provider is out-ofnetwork
with the Plan and authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested 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 office services provided on May 28, 2021, by an
OON provider.