Persius/hicric huggingface dataset:
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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have not been met.  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 that in this case the enrollee was admitted with acute respiratory failure due to coronavirus pneumonia. The record indicates that the enrollee has an elevated white blood cell count, is not clinically stable, and requires ongoing acute care services. 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 she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.   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: 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 can safely receive the services he needs in another setting.  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. There are no acute or complex rehab nursing needs noted in the record. At the current functional level, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Additionally, even if he needed therapy, he would not tolerate the IRF level of intensity for therapies. While the enrollee may benefit from physical and occupational therapy, the enrollee's rehab needs can be safely met in an alternate and lower intensity setting. 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: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that you are requesting more days so that you can get more physical therapy and be able to walk again. You state that they discussed two (2) days a week with home health, but it would not be enough for what you need. The Plan denied your request. The Plan says your records do not show that you require daily skilled nursing services or skilled rehabilitation services. The Plan states the services you require (including routine hemodialysis) can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You appear currently unable to participate in skilled therapy. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, can, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Eliquis tablet.  You asked the Plan to pre-approve Eliquis tablet. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Eliquis tablet.   Benefits for Eliquis tablet 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: Lab
Decision: Favorable

 We decided that the Plan has to pay for the Tempus Gene Panel provided on August 10, 2021.  You asked the Plan to pay for the Tempus Gene Panel. You say that you would like reconsideration because this testing is a Medicare covered benefit. The Plan denied your request. The Plan says that this testing was not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.   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 Tempus Gene Panel. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found next generation sequencing such as with Tempus is a standard of care for patients with metastatic esophageal cancer to determine available targeted therapies and clinical trials.  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 Tempus Gene Panel have been met. Therefore, we decided that the Plan has to pay for the Tempus Gene Panel provided on August 10, 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 SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your request does not show you have skilled nursing or therapy needs that need to be provided on a daily basis as an inpatient only status. The Plan states the services you require can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 you do not qualify for SNF coverage. You do not have documented skilled nursing needs. The exact nature of your wound care is unclear. You do not have documented skilled therapy needs.  You appear to be functioning at/near your baseline. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from February 11, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that you are not able to be moved until Saturday and you have no way to be moved until then. The Plan denied your request. The Plan says you no longer require skilled services and the continuation of SNF 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualify for SNF coverage. You do not have documented skilled nursing needs. Your wound care needs are not complex. You do not have documented skilled therapy needs. You appear to be functioning at/near your baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from February 11, 2022, forward.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 20, 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 shows that the order does not clearly indicate all of the tests to be performed. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 20, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of SNF care from February 9, 2022, forward.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says you no longer require skilled services and the continuation of SNF 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you no longer qualifies for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than one hundred (100) feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of SNF care from February 9, 2022, forward.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for the Guardant360 liquid biopsy.  You asked the Plan to pay for the Guardant360 liquid biopsy. You say that you would like reconsideration because this testing was ordered by your physician and you should not be held liable. The Plan denied your request. The Plan says that this testing was not medically necessary.  The Plan follows Medicare rules. Medicare rules say that [insert custom text from glossary].***}  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 Guardant360 liquid biopsy. Our reviewer says that you meet criteria for testing per LCA: A58192. The service as reasonable and medically necessary. Our physician reviewer found you have metastatic non-small cell lung cancer, your treatment is refractory and the documentation does not indicate that you have had prior Guardant testing.  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 Guardant360 liquid biopsy have been met. Therefore, we decided that the Plan has to pay for the Guardant360 liquid biopsy.   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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the two resin-based composites (D2392 x2) provided on November 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the resin-based composites. You say that you got a basic cavity filling, which the provider advised was covered under your plan. The Plan denied your request. The Plan says these services are not covered.  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. In order to use your OON Flex Benefit, you need to pay for the services up front and then request reimbursement. The record shows that the claim for these services was submitted by the OON provider before you paid for them. Therefore, we decided that the Plan does not have to pay for the two resin-based composites (D2392 x2) provided on November 1, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a heavy duty power scooter.  You asked the Plan to pre-approve the scooter. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence that a manual wheelchair cannot be used.  The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.   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 scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation does not support that your mobility deficit significantly impairs MRADLs in the home. There is no evidence that your deficit cannot be ameliorated by a walker, cane, or manual wheelchair. The documentation does not support that this scooter will significantly improve your ability to participate in MRADLs in the home.  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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a heavy duty power scooter.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that this is to maintain and improve current functional status and prohibit further debility. You state the enrollee needs physical therapy to increase their safety, and quality of life, especially in the facility that the enrollee lives in now. The Plan denied your request. The Plan says the stay 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not qualify for SNF coverage.  The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs, custodial and intermittent, can, as a practical matter, be provided at a lower level of care.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an arterial bypass surgery.  

You asked the Plan to pre-approve the requested services. You say that the enrollee will have a stroke without bypass surgery. The Plan denied your request. The Plan says the service is not covered for the prevention of stroke.  

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 requested services. Our physician reviewer found that in this case the record indicates the requested procedure is for stroke prevention by performing a bypass to the middle cerebral artery.  By rule, extracranial-Intracranial (EC-IC) arterial bypass surgery is not a covered procedure by Medicare when it is performed as a treatment for ischemic cerebrovascular disease of the carotid or middle cerebral arteries.  The elements of the coverage criteria are not satisfied.  

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 an arterial bypass surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoulder arthroscopy rendered on April 8, 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 procedure code 29822 is not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.  The provider submitted a claim for procedure codes 29822 (shoulder arthroscopy with limited debridement) and 29824 (shoulder arthroscopy with distal claviculectomy). Code 29822 is a column II code with a modifier indicator of 1 when billed with column I code 29824. Code 29822 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the shoulder arthroscopy rendered on April 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection service coded as 64488 provided on June 18, 2021.  You asked the Plan to pay for the injection service. You say that this service has been billed correctly. The Plan denied your request. The Plan says the claim has not been billed as required by Medicare coding regulations.  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 64488 is transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; by injections (includes imaging guidance, when performed).  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 injection service. Our reviewer says that the services have been billed incorrectly in this case. Our reviewer found Documentation submitted was reviewed, and the criteria for payment have not been met. Provider billed 2 units for a bilateral code.     Service performed was a bilateral TAP. Services were billed incorrectly, as per the CPT code the description procedure is for a bilateral procedure.  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 injection service have not been met. Therefore, we decided that the Plan does not have to pay for the injection service coded as 64488 provided on June 18, 2021.