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 the stay is medically necessary. The Plan denied your request. The Plan says the enrollee's records show that their rehabilitation needs do not require an intensive team for the enrollee to reach their functional goals. The Plan states the records received do not support that the enrollee requires an intensive therapy program with multiple visits from a rehab doctor per week or that the enrollee is able to actively participate in and benefit from intensive therapy 15 hours per week. The Plan states the enrollee can safely receive the services you need in other settings, for example: a skilled nursing facility or home with home health and home physical therapy.

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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for COVID 19 pneumonia. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health visit provided on November 14, 2020 by an out of network (OON) provider.
You asked the Plan to pay for home health visit. You say that the services that were provided were medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for home health visit provided on November 14, 2020 by an out of network (OON) provider.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay 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 there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. 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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electrical bone growth stimulator (BGS).

You asked the Plan to pre-approve the BGS. You say that this device is needed to help with healing of your femur. The Plan denied your request. The Plan says there is no documentation of the required two x-rays at least 90 days apart.

The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.

In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographs separated by 90 or more days confirming that healing had ceased. Therefore, we decided that the Plan does not have to pre-approve an electrical bone growth stimulator (BGS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve power wheelchair. You say that you would not be able to open or fold a manual wheelchair and need a power mobility device to move around. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you can use a manual wheelchair.
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 power wheelchair. Our reviewer says that you do not meet the Medicare criteria for a power wheelchair. Our physician reviewer found there is no documentation that you have a personal mobility deficit that impairs participation in mobility-related activities of daily living such as toileting, feeding, grooming, and bathing in customary locations within the home. The documentation does not show that your mobility deficit cannot be helped by the use of a walker, cane, or manual wheelchair. There is no documentation that you can safely operate a power mobility device. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rosuvastatin.
You asked the Plan to pre-approve Rosuvastatin. You say that the medication is necessary. The Plan denied
your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Rosuvastatin.
Benefits for Rosuvastatin 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425), provided on September 8, 2020.
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport
(A0428, A0425). The Plan denied your request. The Plan says ambulance transport to or from an outpatient office or facility is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport (A0428, A0425). Our reviewer says that ambulance services are not medically necessary. Our physician reviewer found that in this case, the enrollee was transported by stretcher for office evaluation of back pain that had been present for four years. The provided records do not demonstrate the medical necessity for ambulance transportation or that a different mode of transportation, such as stretcher van, would not have been appropriate for the enrollee. The elements of the coverage rule are not satisfied. The requested service cannot be recommended. 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 ambulance service, basic life support, non-emergency transport
(A0428, A0425) have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425), provided on September 8, 2020.
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 stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

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 complexity of your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
left sided weakness. Medical conditions 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. You do require physical and occupational therapy but there is no
documented need for an intensive rehabilitation program. Medically necessary services 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on December 18, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered were not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Guardant360 testing is only covered for certain indications. 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 testing. Our reviewer says that the documentation does not support that the services rendered were medically reasonable or necessary. Our physician reviewer found the enrollee has stage III intermediate risk adenocarcinoma of the prostate. The enrollee was started on Lupron and Casodex therapy. Although the records show that this enrollee has advanced stage cancer and had not yet been tested with the same test, there was no indication from the notes that there was an intention to seek further treatment beyond the hormone therapy to help meet the criteria for this test. Therefore, the enrollee did not meet criteria for the services rendered. 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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the gradient compression stockings (CPT code A6533)
purchased on August 13, 2020.
You asked the Plan to pay for the gradient compression stockings. You say that you order just two pair per year
as a means of preventing larger medical problems to come, even if regular Medicare restricts purchase to the
higher strengths, which are not appropriate for your physical condition. The Plan denied your request. The Plan
says this item is not covered. The Plan must follow Medicare rules. We looked at the file and Medicare rules.
Based on this information, we decided that Medicare rules for coverage of the gradient compression stockings
have not been met. The rules say the following are examples of wound care items which are non-covered under
the surgical dressing benefit because they do not meet the statutory definition of a dressing (not all-inclusive):
Gradient compression stockings (CPT code A6533). Therefore, we decided that the Plan does not have to pay
for the gradient compression stockings (CPT code A6533) purchased on August 13, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient office visit (G0463) provided on November 16, 2020, by an out of network (OON) provider.
You asked the Plan to pay for an outpatient office visit. You say that you would like to request reconsideration for the denied claim. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for outpatient office visit care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for an outpatient office visit. Therefore, we decided that the Plan does not have to pay for an outpatient office visit (G0463) provided on November 16, 2020, by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's care could be given at a lower level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for thoracolumbar
spinal surgery. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation
needs. The patient does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and
occupational therapy but there is no documented need for an intensive rehabilitation program. Medically
necessary services can be provided in a different level of care. There is not a reasonable expectation that this
patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program
provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for IRF care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on December 24, 2020.

You asked the Plan to pay for the non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888). You say that the Plan has always covered the ambulance services in the past and you cannot afford to pay the bill. The Plan denied your request. The Plan says the additional ambulance transportation mileage is not considered medically reasonable and necessary because a closer facility was able to meet your needs.

The Plan must follow Medicare rules. Medicare rules say that Medicare only covers ambulance transportation to the nearest appropriate facility.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional ambulance mileage (A0888) have not been met. Specifically, the record shows that you received transportation services beyond the nearest appropriate facility. This means that the additional ambulance mileage is not covered by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) (A0888), provided on December 24, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for sedation services (99153) provided January 4, 2021.

You asked the Plan to pay for the sedation services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim is not payable as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 has a Professional Component (PC)/Technical Component (TC) indicator of 3 per the January 2021 National Physician Fee Schedule. This code is not separately payable for this place of service. Based on this information, we decided that Medicare rules for coverage of the sedation services have not been met. Therefore, we decided that the Plan does not have to pay for sedation services (99153) provided January 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tempurpedic mattress (E1399).

You asked the Plan to pre-approve this item. You say that this item is medically necessary for the enrollee. The
Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's contractual policy
or by Medicare.

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. A tempurpedic
mattress is not designed primarily to treat a medical condition. This is available to the general public without a
prescription. There may be mattresses that can be used with a hospital bed that could be approved if Medicare
coverage criteria are met but the tempurpedic mattress is not a medical-grade hospital bed mattress. Therefore,
we decided that the Plan does not have to pre-approve a tempurpedic mattress (E1399).