Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by a non-participating provider on September 28, 2020, to October 2, 2020.
You asked the Plan to pay for inpatient hospital care. You say that you would like reconsideration based on the medical records provided. The Plan denied your request. The Plan says the documentation does not support any kidney injury. The evidence points to transient pre-renal azotemia post-operatively that resolved quickly with fluids.
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 DRG 474, Acute Tubular Necrosis. 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 inpatient hospital care. Our reviewer says that the medical records supported the DRG downgrade from 474 to 475. Our physician reviewer found on admission the enrollee's creatinine is 1.0. Post-operative day one it was 1.4, then trended down. Nephrology was not consulted on this admission. Acute tubular necrosis was not documented in the documents that were received, and not in the discharge summary. 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 inpatient hospital care provided on September 28, 2020, to October 2, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 23, 2021, through March 31, 2021.

You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment should be made for these services. The Plan denied your request. The Plan says Medicare coverage for the SNF services at issue was correctly denied.

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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of 2/23/2021, the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 2/23/2021. 

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 pay for the skilled nursing facility (SNF) services provided from February 23, 2021, through March 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the deductible for the anesthesia services provided on January 25, 2021.
You asked the Plan to reduce the deductible for the anesthesia services. You say that the cost share should not be more than $10.00. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible which applies to anesthesia services. The anesthesia services you asked the Plan to reduce the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to the anesthesia services. This cost sharing is a contractual obligation that had not been met at the time the anesthesia services was received on January 25, 2021. Therefore, we decided that the Plan does not have to reduce the deductible for the anesthesia services provided on January 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on May 20, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you are appealing this claim. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for each Medicare-covered individual or group visit.
You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Outpatient mental health care" 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 office visit provided on May 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve multiple venous procedures intravascular ultrasound, 
angioplasty, and stenting with sedation. 
 
You asked the Plan to pre-approve multiple venous procedures intravascular ultrasound, angioplasty, and 
stenting with sedation. You say that there are no rules that state the enrollee needs to have a CT or MRI done 
before coverage for the requested codes will be allowed. The appellant says that the enrollee has persistent 
swelling and pain in bilateral legs, which is now affecting daily activities. The appellant says that the enrollee 
also has ulcerations to both legs. The appellant says that the requested procedures are medically necessary, will 
check if the enrollee has compression to the iliac vein, and rule out May-Thurner syndrome. The Plan denied 
your request. The Plan says the requirements for approval have not been met. The Plan says that the records do 
not show that the enrollee has acute symptoms, such as blood clots. The Plan says that the enrollee has not had 
initial testing such as computed tomography (CT) or magnetic resonance imaging (MRI). 
 
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 multiple venous procedures 
intravascular ultrasound, angioplasty, and stenting with sedation. Our reviewer says that the requested services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found a plan for 
invasive venography and possible intervention was made prior to obtaining the noninvasive studies that were 
ordered. The enrollee has a history of diabetes and hypertension, and, on the right, the ulcer is on the first toe. It 
is unclear if this is a venous stasis ulcer.  The ulcer on the left is described as a skin ulcer and is not otherwise 
characterized.  There is no documentation of whole leg swelling in either leg in the physical examination.  A 
conservative treatment regimen was outlined, but there is no documentation as to the success of these efforts.  
The treatment plan does not incorporate the findings of the lower extremity venous duplex results. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of multiple venous procedures intravascular ultrasound, angioplasty, and stenting 
with sedation have not been met. Therefore, we decided that the Plan does not have to pre-approve multiple 
venous procedures intravascular ultrasound, angioplasty, and stenting with sedation.
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 service. You say that the records provided support the need for SNF care. You say that you have 32 steps to get into your house and that you are not able to walk. You say that you need skilled nursing services. The Plan denied your request. The Plan says the enrollee has no daily skilled nursing or therapy needs.

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 service. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and used oxygen via a nasal cannula. The enrollee continued dialysis. The enrollee received physical therapy and occupational therapy. The enrollee was at an independent to stand by assist level with functional mobility, including gait to 40 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF service have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says SNF care is not reasonable and necessary for treatment of the enrollee's condition. The Plan says that the enrollee's needs can be met at 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and used oxygen via a nasal canal. The enrollee received physical therapy and occupational therapy. The enrollee was at maximal assist level with transfers and required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management (EM) services provided on April 22, 2021, billed with code 99310.

You asked the Plan to pay for the EM services as billed. You say that this was billed correctly. The Plan denied your request. The Plan says the enrollee does not meet criteria for skilled nursing facility care.

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 99310 is Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; 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.

The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient's facility floor or unit. 

We find that CPT code 99310 is not supported in the medical record. Specifically, this code is for use when providing care to a skilled nursing facility resident. The enrollee was treated in an assisted living facility. This code is not appropriate for this situation. Based on this information, we decided that Medicare rules for coverage of the EM services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation and management (EM) services provided on April 22, 2021, billed with code 99310.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Amitiza.

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 self-administered drugs are not covered.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Amitiza.

Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional outpatient physical therapy visits.
You asked the Plan to pre-approve outpatient physical therapy. You say that your physicians are prescribing physical therapy for your conditions. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the remaining approved visits should be enough to finish your care and additional visits are not needed.
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 outpatient 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 additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was already approved by the Plan. You have had 35 prior therapy visits and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, and that the services can be safely and effectively performed only by a therapy or under the supervision of a therapist. You have been instructed in a home exercise program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of outpatient physical therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve additional outpatient physical therapy visits.
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 medical records provided support the need for foot orthotics. 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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered on June 16, 2020 to
July 13, 2020.

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 the claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that the Form CMS-1450, also known as the UB-04 form,
is a uniform institutional provider bill used in billing multiple third party payers.

We looked at the file and Medicare rules. The file shows that the claim was not billed on the required uniform billing form. 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 pay for the inpatient hospital services rendered on June 16, 2020 to July 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the iron serum testing rendered on April 13, 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 the services were not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that iron serum studies are covered when specific criteria are met. 

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 these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the records show that you received iron, iron binding capacity, and ferritin testing. There is no clinical condition in the records for which the testing would be warranted. There is no documentation to support that the testing would lead to a change in treatment. The services were therefore 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 pay for the iron serum testing rendered on April 13, 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 SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says 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 you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parental medication; complex wound care or nutrition given via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near his baseline and he can receive services at a lower level of care. Admission to a SNF for inpatient skilled rehab services 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 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: 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 meet criteria for an IRF admission. The Plan denied your request. The Plan says the documentation fails to indicate that you require a multidisciplinary approach with specialized therapies, specialty rehabilitation nursing, and physician oversight at least 3 times per week.

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 the complexity of your nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical
problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multidisciplinary
rehabilitation program. There is not a reasonable expectation that you 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.