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

We decided that the Plan does not have to pay for the acute inpatient hospitalization.
You asked the Plan to pay for acute inpatient hospitalization. You say that the service is medically necessary.
The Plan denied your request. The Plan says the service is not medically necessary.
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 hospitalization. Our reviewer
says that the service is not medically necessary. Our physician reviewer found the record does not document
that the treating physician has a reasonable expectation of a length of stay spanning two or more midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospitalization have not been met. Specifically, medically
necessary services can be obtained at a lower level of care. This inpatient hospitalization is not medically
necessary or reasonable. Therefore, we decided that the Plan does not have to pay for the acute inpatient
hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion interspinous spacer device coded as 22869 and 22870.
You asked the Plan to pre-approve the Vertiflex Superion device. You say that the medical records provided will show proof of medical necessity The Plan denied your request. The Plan says the requested device is considered experimental. More research is needed to show safety and efficacy.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of Vertiflex Superion interspinous spacer device coded as 22869 and 22870.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient psychiatric hospitalization. 
 
You asked the Plan to pre-approve the inpatient psychiatric hospitalization. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

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 the inpatient psychiatric hospitalization. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found it is not expected 
this enrollee would improve in a reasonable period of time as they did not have dangerousness to self or others 
and was not showing any auditory/visual hallucinations or any aggressive behaviors. 
 
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 inpatient psychiatric hospitalization have not been met. Specifically, 
medically necessary services can be obtained at a lower level of care. This means inpatient psychiatric 
hospitalization is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to 
pre-approve the inpatient psychiatric hospitalization.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro 2 Motion G orthotic device for the enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that peer reviewed literature considers the use of robotic therapy for upper and lower extremity stroke rehabilitation to be investigational in nature with no long-term outcome data at this time.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Current guidelines designate robotic therapy to be of "uncertain utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the home environment. The documentation also reports the enrollee has shoulder subluxation which may be a contraindication to the use of the requested device. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.
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 a MyoPro 2 Motion G orthotic device for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient services provided from September 23, 2019, to 
October 4, 2019, and billed with diagnosis related group (DRG) 690. 
 
You asked the Plan to pay for the inpatient services billed with DRG 690. You say that these services were 
medically necessary and billed correctly. The Plan denied your request. The Plan says the documentation 
supports a primary diagnosis of sepsis (A41.9) with a secondary diagnosis of severe sepsis without shock 
(R6520). However, unspecified kidney failure (N179) and severe sepsis with septic shock (R6521) are not 
supported. The Plan says the record best supports DRG 871. 

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 690. We asked our physician reviewer to 
carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in 
denying the request to pay for the inpatient services billed with DRG 690. Our reviewer says that the medical 
records do not support the billing of unspecified kidney failure and severe sepsis with septic shock. Our 
physician reviewer found that given the development of hypotension and mental status alteration in the setting 
of urinary tract infection (pyelonephritis and prostatitis), with initial presentation with lactic acid elevation and 
elevated total bilirubin level, which were otherwise unexplained, the principal diagnosis code for Sepsis is 
considered to be substantiated by the hospital record. In accordance with Sepsis 3 guidelines, the diagnosis of 
Severe sepsis with septic shock requires the diagnosis of Sepsis, lactic acid level of greater than 2.0mmol/L, 
despite fluid resuscitation, and vasopressor administration. In this case, while under consideration, the member 
ultimately did not require vasopressor support. As the member did not require vasopressor support, the 
secondary diagnosis code for Severe sepsis with septic shock is not substantiated. The review has determined 
that the medical records did not support the billing of unspecified kidney failure and severe sepsis with septic 
shock. 
 
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 inpatient services billed with DRG 690 have not been met. Therefore, we 
decided that the Plan does not have to pay for inpatient services provided from September 23, 2019, to October 
4, 2019, and billed with diagnosis related group (DRG) 690.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat-lift mechanism.
You asked the Plan to pre-approve a seat-lift mechanism. You say that this request is medically necessary. The
Plan denied your request. The Plan says the criteria for a seat lift mechanism have not been met.
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions
listed in the Medicare rules section 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 pre-approve a seat-lift mechanism. Our reviewer
says that the requested item is not medically reasonable and necessary. Our physician reviewer found the
review indicates that the enrollee has chronic comorbidities including systemic lupus syndrome degenerative
disc disease requiring the use of disease modifying medications in consultation with Rheumatology. The
review indicates that the patient does not severe arthritis of the hip; and/or (b) a neuromuscular disease. In
addition, the records do not show that the patient is completely incapable of standing from a chair in the home.
Thus, the coverage criteria have not been met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a seat-lift mechanism have not been met. Therefore, we decided that the Plan
does not have to pre-approve a seat-lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
You asked the Plan to pre-approve Vertiflex. You say that this is a safer alternative to laminectomy or open decompression. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Vertiflex is experimental/investigational.
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 Vertiflex. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental, more research is needed to show its safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the enrollee was approved for a total shoulder arthroplasty and will need inpatient admission after surgery. The Plan denied your request. The Plan says there is no documentation provided to support the expectation the enrollee will require 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 pre-approve 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 enrollee is scheduled for a total shoulder arthroplasty. The record does not document that the treating physician has a reasonable expectation of a length of stay spanning 2 or more midnights. The enrollee may be admitted for observation. 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 pre-approve acute inpatient hospital care.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90832) provided February 23, 2021.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that for outpatient mental health services to be covered, the provider must consult with the enrollee's primary or attending physician. We looked at the file and Medicare rules. The documentation does not show any consultation with the enrollee's primary physician, or any documentation of a failed attempt to consult with the enrollee's primary physician. Based on this information, we decided that Medicare rules for coverage of the outpatient mental health services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (90832) provided February 23, 2021.
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 continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve spine surgery identified with codes 20930, 20936, 22600, 22614, 22843, 63045, and 63048.
You asked the Plan to pre-approve spine surgery. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 spine surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found criteria for cervical fusion surgery not met. There is no documented spinal instability or severe cord compression on imaging. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spine surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve spine surgery identified with codes 20930, 20936, 22600, 22614, 22843, 63045, and 63048.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office visit. You say that you have been seeing this provider and have developed a deep connection. You feel that it is important to have continuity of care. You do not want to start all over with another therapist. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99213) to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the gingival irrigation and localized delivery of antimicrobial agents.
You asked the Plan to pre-approve the gingival irrigation and localized delivery of antimicrobial agents. You say that the other services are needed with the deep cleaning and should be approved. The Plan denied your request. The Plan says the services are not covered 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 pre-approve the gingival irrigation and localized delivery of antimicrobial agents.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with multiple 
power options (coded as K0861) with a power tilt/recline seating system, among other accessories.

You asked the Plan to pre-approve the K0861 Group 3 PWC with multiple power options. You say that this is 
medically necessary. The Plan denied your request. The Plan says a Group 3 PWC with no power options could 
be approved if requested, but the criteria for the multiple power options are not met. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 PWC with multiple power options is 
covered when the criteria in the Medicare rules section 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 pre-approve the K0861 Group 3 PWC with multiple 
power options. Our reviewer says that the criteria for the specific type of PWC requested are not met in this 
case. Our physician reviewer found the patient does not use a ventilator mounted to the wheelchair and does 
not meet coverage criteria for a power tilt and power recline seating system. There is no evidence of 
intermittent catheterization, spasticity that needs to be managed with a power seating system. The 
documentation does not reveal that the patient is at high risk for a pressure ulcer. The patient is reported to have 
a normal Get Up and Go Test which indicates he can rise up from a chair and walk. He has had no falls. He is 
noted on neurologic test to have normal motor movement in all extremities.  
 
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 K0861 Group 3 PWC with multiple power options have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair (PWC) with 
multiple power options (coded as K0861) with a power tilt/recline seating system, among other accessories.