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

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that you are medically ready to discharge from the acute care setting and need to go to rehabilitation in order to go home safely. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services you requested do not meet the requirements for approval.

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 you were admitted for surgical management of an olecranon fracture and no surgical management of pelvic and sacral fractures after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that you are requesting reconsideration for the denial of 
a SNF admission. The Plan denied your request. The Plan says the SNF services requested do not meet the 
requirements for approval. 
 
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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (SNF) setting. Daily skilled services are not shown to be required to establish a maintenance program 
or to prevent deterioration of the enrollees condition. 
 
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 skilled nursing facility (SNF) care.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says that the requested admission to an IRF does not meet criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that 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's medical conditions appear improved on stable medications with no issues that appear to require a physician's evaluation three or more times per week in a hospital setting. The patient does require physical therapy and occupational therapy services, but the medical records provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. Provided medical records do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care such as in a skilled nursing facility is not appropriate for the patient. There is concern that the patient will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his poor endurance and his "fatigue quickly" with rehab. Our Medical Director 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 continued skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that you do not meet the criteria for a continued inpatient stay at the SNF. Maximus overturned the Plan's denial because they did not provide a valid Notice of Medicare Non-Coverage (NOMNC). The Plan requested a reopening and provided a valid signed NOMNC.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for continued SNF care. Our Medical Director states that the clinical documentation does not support that it is/was medically reasonable and necessary to provide continued skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing facility setting. Our Medical Director found that the enrollee's condition does not meet Medicare criteria for continued SNF 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 continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for April 3, 2023. 
 
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 93042 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. 
 
In this case, the CPT Code Manual definition of code 93042 is rhythm ECG, 1-3 leads; interpretation and 
report only. 
 
We find that CPT code 93042 is not supported in the medical record. Specifically, the records do not show that 
electrocardiogram (ECG) testing was performed for reasons other than cardiac rhythm monitoring. 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 procedure code 93042 billed for April 3, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 8, 2022, to June 
12, 2022, at the Diagnosis Related Group (DRG) originally billed. 
 
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that 
principal diagnosis N17.9 is supported in the documentation, therefore the claim should be paid at the DRG 
originally billed. The Plan denied your request. The Plan says principal diagnosis N17.9 is not supported in the 
documentation. 
 
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 principal diagnosis code N17.9, defined as acute 
kidney failure, unspecified. 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 
hospital services at the DRG originally billed. Our reviewer says that principal diagnosis N17.9 is not 
supported in the documentation. Our physician reviewer found that this enrollee with history of chronic kidney 
disease stage 5, cognitive decline, and uterine cancer presented with abdominal pain. They were found to have 
a creatinine level of 5.45, which was 5.71 the month prior. The enrollee had chronic kidney disease and does 
not meet criteria for superimposed acute kidney injury, so code N17.9 is not justified.  
 
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 services provided on June 8, 2022, to June 12, 2022, at the Diagnosis Related Group 
(DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for dates of service March 20, 
2023. 
 You asked the Plan to pay for the billed services. You say that the date and time submitted is the actual date the 
services were rendered. 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in 
the medical record. The records do show a dictation and transcription date/time. It is possible for dictation and 
transcription to occur after a service was provided. In this case, there is insufficient evidence to confirm that the 
transcription and dictation was provided at the time the actual services were rendered. Based on this 
information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99291 billed for dates of service March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 81301 and 81194 billed for date of service 
January 16, 2023. 
 You asked the Plan to pay for procedure codes 81301 and 81194. The Plan denied your request. The Plan says 
payment for codes 81301 and 81194 is bundled into payment for code 81455. 
 
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, we have confirmed that codes 
81301 and 81194 are column II codes to column I code 81455. This claim has not been billed with an 
appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure codes 81301 and 81194 billed for 
date of service January 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a protective helmet (E1399). 
 
You asked the Plan to pre-approve a helmet. You say that the enrollee has been scratching their ear off and can 
end up losing the ear. The Plan denied your request. The Plan says a helmet is not considered a covered DME 
item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a protective helmet (E1399).
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 enrollee needs the IRF admission. The Plan denied your request. The Plan says the enrollee's rehabilitation needs do not require an intensive team approach.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted for hypotension, falls, anemia, and a hematoma of the knee. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the water circulating heat pad with pump (E0217) provided 
on February 22, 2023, through March 14, 2023. 
 
You asked the Plan to pay for the water circulating heat pad with pump.. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that if code E0215 or E0217 is provided it will be 
denied as not reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the water circulating heat pad with pump have not been met. Therefore, we decided that the Plan 
does not have to pay for the water circulating heat pad with pump (E0217) provided on February 22, 2023, 
through March 14, 2023.
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 the enrollee has had extensive physical, occupational, and speech therapy along with intensive nursing care, but still has significant cognitive deficits and would be unsafe to be at home alone. The Plan denied your request. The Plan says that based on Medicare guidelines, the IRF services requested do not meet the requirements for approval.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for IRF care. Our Medical Director states that 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's medical conditions appear improved on stable outpatient medications with no issues that appear to require a physician's evaluation three or more times per week in a hospital setting. The patient does require physical therapy and occupational therapy services, but the medical records provided do not clarify why the patient requires an intensive inpatient rehabilitation therapy program. Provided medical records do not support that the intensive inpatient rehabilitation therapy program is necessary and that therapy at a lower level of care such as in a skilled nursing facility, at home with home health care or as an outpatient is not appropriate for the patient. The patient would be expected to participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility, however, the medical records do not support a complexity of needs to require an acute inpatient rehabilitation facility over a skilled nursing facility or home health care or outpatient care. Our Medical Director 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cobalt-based stereotactic radiosurgery (GammaKnife). 
 
You asked the Plan to pre-approve GammaKnife. You say that you need this treatment to remove your tumor. 
The Plan denied your request. The Plan says this technique cannot treat extracranial targets, that would be 
impossible. 
 
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 GammaKnife. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the records do not demonstrate the necessity of this procedure when the treatment is not the 
standard of care for routine practice. The request for cobalt-based GammaKnife is likely an error. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of GammaKnife have not been met. Therefore, we decided that the Plan does not 
have to pre-approve cobalt-based stereotactic radiosurgery (GammaKnife).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an intraosseous ablation of the basivertebral nerve. 
 
You asked the Plan to pre-approve an intraosseous ablation of the basivertebral nerve. You say that the enrollee 
has tried and failed non-operative treatment. The Plan denied your request. The Plan says the medical criteria 
for this procedure have not been met. 
 
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 an intraosseous ablation of the 
basivertebral nerve. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the magnetic resonance imaging (MRI) 
does not describe modic endplate changes. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an intraosseous ablation of the basivertebral nerve have not been met. 
Therefore, we decided that the Plan does not have to pre-approve an intraosseous ablation of the basivertebral 
nerve.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure at L5-S1. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that this procedure is considered 
experimental. The Plan denied your request. The Plan says the enrollee says that they are in a lot of pain, and 
they are afraid if this procedure is denied that they will relapse. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no magnetic resonance imaging (MRI) showing only modic changes without 
facet joint disease or stenosis. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure at L5-S1.