Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular genetic screening panel testing provided on October 3, 2020.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

The tests at issue in this appeal, genetic testing, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular genetic screening panel testing provided on October 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingivectomy (D4211) for tooth # 31 provided on January 13, 2021.
You asked the Plan to pay for the dental service. You say that you do not have a way of knowing that this service would not be covered. You also say that you think the dentist would not have performed this service if it was not necessary. The Plan denied your request. The Plan says gingivectomy is not listed as a covered service.
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 pay for the gingivectomy (D4211) for tooth # 31 provided on January 13, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided October
30, 2020, to November 29, 2020.

You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for the SNF
services. The Plan denied your request. The Plan says the enrollee did not meet the criteria for SNF admission.
The enrollee could receive the care needed in another setting, such as home with home health care, a long-term
care facility, or other outpatient setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing
and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily
basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled
nursing facility setting.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does
not have to pay for the skilled nursing facility (SNF) services provided October 30, 2020, to November 29,
2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve amlodipine besylate 5 mg.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve amlodipine besylate 5 mg.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve an Inogen portable oxygen concentrator.

You asked the Plan to pre-approve portable oxygen concentrator. You say that you are only able to walk for 3
minutes before requiring oxygen, and your current oxygen equipment is impossible for you to use in your
condition. The Plan denied your request. The Plan says that the denial of authorization for this item is correct,
because this is not medically necessary, and you already have oxygen equipment at home.

The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify
for oxygen solely based on blood gas studies obtained during sleep.

To qualify for home oxygen, the patient must meet one of the following blood gas levels:
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during
sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for
patients who have hypoxia symptoms during exercise;
4. Arterial PO2 between 56 and 59 mm Hg and arterial O2 saturation is 89% on room air if there is evidence of
dependent edema, pulmonary hypertension, or erythrocythemia.

For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air,
there is a rebuttable presumption of non-coverage.

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 portable oxygen concentrator. Our
reviewer says that you meet the Medicare criteria for the requested portable oxygen concentrator. Our
physician reviewer found you have chronic lung disease and require supplemental oxygen with activity within
the home. According to the appeal, you are unable to manage the portable tanks that have been provided.
Medicare covers portable oxygen equipment for mobility within the home and this portable oxygen
concentrator is medically reasonable and necessary because you cannot manage heavier tanks.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of portable oxygen concentrator have been met. Therefore, we decided that the
Plan has to pre-approve an Inogen portable oxygen concentrator.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous airway pressure device (CPAP) and humidifier.

You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says there is non-compliance evident.

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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the case file does not contain sufficient medical records to determine whether you qualify for the continued use of the requested service.

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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous airway pressure device (CPAP) and humidifier.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cardiology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve cardiology services. You say that you cannot successfully locate an in-network physician to treat you. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network specialist.

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 cardiology services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Udenyca.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has stage IIIB non-small cell lung cancer and is on cisplatin/pemetrexed. Although he is receiving a chemotherapy regimen with a low risk of neutropenic fever, he has the additional risk factors of recent surgery and age greater than 65 years while receiving full dose chemotherapy. In addition, his ANC is low just prior to his next cycle of chemotherapy. The use of Udencya is reasonable and medically necessary to prevent neutropenic fever. 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 been met. Therefore, we decided that the Plan has to pre-approve Udenyca.
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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve surgical correction of a bunion.

You asked the Plan to pre-approve foot surgery. You say that you need to be treated by this provider. The Plan denied your request. The Plan says that the medical records do not support the medical necessity of this procedure.

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 pre-approve foot surgery. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found it is well established that you suffer from painful bunion deformities on both feet, the left greater than the right. You have difficulty ambulating and wearing shoes due to your painful bunions. Physical examination demonstrates lateral deviation of left hallux, with prominence of the first metatarsal head noted medially. Irritation and pain are noted in this area. You had X-Ray confirmation of a hallux valgus deformity on the left side. The requested surgical correction meets the Medicare guidelines for coverage.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of foot surgery have been met. Therefore, we decided that the Plan has to pre-approve surgical correction of a bunion.

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: 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 ongoing skilled therapy and nursing needs can be provided 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for non-operative management of pelvic and iliac wing fractures after a fall. 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 a not 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for neurology services (CPT 95861, CPT 95868, CPT 95927, CPT 95938, CPT 95939) provided to the enrollee on July 17, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the records do not support the services billed, as they were billed from an inappropriate place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say that if a mobile unit is serving an entity for which another POS code already exists, providers should use the POS code for that entity.
In this case, the CPT Code Manual definition of the denied codes is: CPT 95861: Needle electromyography; two extremities with or without related paraspinal areas CPT 95868: Needle electromyography; cranial nerve supplies muscles, bilateral CPT 95927: Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head CPT 95938: Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs CPT 95939: Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the place of service is incorrectly reported as the hospital is a POS code 21 facility, and as such, the technical component is billed appropriately by the hospital. The requested service is not billed with the appropriate modifier. 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 services have not been met. Specifically, the record shows that the services at issue were provided for a patient receiving services in a hospital. This means that the billed Place of Service 15 - mobile unit is not supported. Therefore, we decided that the Plan does not have to pay for neurology services (CPT 95861, CPT 95868, CPT 95927, CPT 95938, CPT 95939) provided to the enrollee on July 17, 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 records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the enrollee can safely receive the services needed in other settings such as a skilled nursing facility, home with home health services or home with outpatient 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 enrollee was admitted for COVID 19 pneumonia. Medical conditions are stable.
There are no complex nursing or rehabilitation needs. The enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an out-of-network provider.

You asked the Plan to pre-approve an out-of-network consultation. You say that you need bioidentical
compound hormones. You say that your doctor referred you out-of-network because there are no in-network
physicians trained for these services. The Plan denied your request. The Plan says in-network providers are
available.

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
a consultation with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 2 administrations of therapeutic parenteral drug (D9612).
You asked the Plan to pre-approve the dental service. You say that you need this service. You say that dental surgery is hard to have without getting numb. You say that The Plan denied your request. The Plan says 2 administrations of therapeutic parenteral drug is not listed as a covered service.
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 2 administrations of therapeutic parenteral drug (D9612).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ongoing negative pressure wound therapy (NPWT)
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says the measurements did not show improvement in wound size.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that prior use of this device has resulted in any improvement. As such, ongoing use of negative pressure wound therapy device is not shown to be medically necessary of reasonable. 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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve ongoing negative pressure wound therapy (NPWT)