Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the E extra-long full mattress (99499).
You asked the Plan to pre-approve the E extra-long full mattress. You say that the item is medically necessary. The Plan denied your request. The Plan says there is no mention in the medical records that the member uses or needs a hospital bed. Mattresses are only covered if the beneficiary needs a hospital bed and owns one for medical reasons.
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 the E extra-long full mattress (99499).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the doctor has performed the tests to confirm that the pain is coming from the sacroilaic joint.
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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical value and effectiveness of a sacroiliac joint injection in the absence of tenderness and negative provocative testing results have not been demonstrated in the peer-reviewed literature. In this case, there is no documentation on physical examination of tenderness to the sacroiliac joint and no mention of SI provocative testing being completed with positive findings. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a sacroiliac joint injection for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room services provided on December 21,
2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says complete
medical records are needed.
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 99285 is emergency department visit for the evaluation
and management of a patient. Usually, the presenting problem(s) are of high severity and pose an immediate
significant threat to life or physiologic function.
We find that CPT code 99285 is not supported in the medical record. The records show that the enrollee was
treated for a cough and sore throat. The enrollee's lungs were clear and had stable vital signs. The records
provided do not show the enrollee's presenting problems were of high severity. 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 the emergency room services provided on December 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Ventolin provided in an outpatient setting on April 1, 2021.

You asked the Plan to pay for the self-administered drug. You say that this was a rescue inhaler. You say that you have used this medicine for most of your life. You also say that you have never had this issue. The Plan denied your request. The Plan says the drug you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug you received is not covered under Medicare Part B.

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 pay for the Ventolin provided in an outpatient setting on April 1, 2021.

Benefits for the self-administered drug 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: 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 IRF care is detrimental to your health and recovery. You say that IRF care is needed in order for you to return home. The Plan denied your request. The Plan says the enrollee's complexity of care is low, and her rehabilitation needs are also not complex enough to require coordinated care between therapy disciplines. The Plan says that IRF care 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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. The enrollee's medical conditions 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. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104), and diagnostic casts (D0470) provided on January 14, 2021.
You asked the Plan to pay for a bone graft at time of implant placement, and diagnostic casts. You say that the services were necessary. The Plan denied your request. The Plan says the services at issue are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone graft at time of implant placement (D6104), and diagnostic casts (D0470) provided on January 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) and abutment
supported crown (D6058) provided on February 10, 2021.
You asked the Plan to pay for the custom fabricated abutment (D6057) and abutment supported crown
(D6058). You say that this was the first-time having implants and you never received a document showing
these services are not covered. The Plan denied your request. The Plan says the services are not covered
benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
custom fabricated abutment (D6057) and abutment supported crown (D6058) provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the radiation therapy (77280, 77771) provided on October 29, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $65 copayment for radiation therapy at a specialist's office or freestanding radiological facility. You have been asked to pay a $65 copayment for the radiation therapy provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to adjust the copayment for the radiation therapy (77280, 77771) provided on October 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 19, 2019.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 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 physician services provided to the enrollee on June 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IVIG therapy.
You asked the Plan to pre-approve the IVIG therapy. You say that you would like reconsideration because IVIG therapy is medically necessary. The Plan denied your request. The Plan says the member has not tried and failed a trial of Prednisone.
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 IVIG therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the clinical documentation provided for review suggested that the member may have chronic inflammatory demyelinating polyneuropathy (CIDP). It was not clear from the notes provided if the neuropathy was primarily axonal versus demeylinating. Nor was there sufficient information provided from a neurological exam to support the condition. As such a diagnosis of CIDP in this case would be "uncertain". In such as setting a trial of steroids prior to consideration of IVIG is necessary. There was no documentation of a trial of steroids.
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 IVIG therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve IVIG therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Rituxan Hycela.

You asked the Plan to pre-approve Rituxan Hycela. You say that using Rituxan Hycela is faster than other treatments. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because Rituxan Hycela is not indicated for non-malignant conditions.

The Plan follows Medicare rules. Medicare rules state that Rituxan Hycela may be covered for certain uses, but is not indicated for the treatment of non-malignant conditions. 

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 Rituxan Hycela. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of Rituxan Hycela. Our physician reviewer found the supported drug compendia do not currently support the use of Rituxan Hycela for this condition, whereas Rituxan is supported and was approved. Therefore, this request for Rituxan Hycela is not medically necessary at this time.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan Hycela have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Rituxan Hycela.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines and the information we have about the enrollee's condition; the enrollee does not meet all the requirements.
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 the enrollee has a history of hypertension, congestive heart failure, and chronic kidney disease who was recently hospitalized and currently admitted to the skilled nursing facility (SNF) for deconditioning after recovering from respiratory failure secondary to aspiration pneumonia with metabolic encephalopathy and bilateral pleural effusions. Per the SNF progress note on August 11, 2021, the enrollee had Steri-Strips placed on a scalp laceration after a fall which appears clean, dry, and intact. The friction tears on the shoulders have resolved. The enrollee is afebrile, has no cough, has no shortness of breath, and is on 2
liters/minute of oxygen via nasal cannula. The most current therapy notes on July 13, 2021 documents that the enrollee has marked deficits in mobility and cognition to complete activities of living and has reduced safety awareness. There is no documentation provided indicating medical necessity for the requested LTACH services. 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 he is 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 LTACH services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care following the total hip replacement (CPT code 27130), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the services are necessary. The Plan denied your request. The Plan says the enrollee is medically stable and has already been provided medical clearance to undergo this elective procedure. The Plan states the planned procedure listed under CPT code 27130 is not listed on the CMS Inpatient Only List and the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the planned procedure listed under CPT code 27130 is not listed on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only List. The arthroscopy procedure is currently approved as an ambulatory outpatient procedure. There is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The review has determined that the record did not show that inpatient hospital care is necessary for this procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital care following the total hip replacement (CPT code 27130), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute inpatient hospital care associated with an already approved elective surgery.
You asked the Plan to pay for acute inpatient hospital care. You say that inpatient admission is medically necessary. The Plan denied your request. The Plan says there is no documentation provided to support the expectation you will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found based on the provided documentation, you are a low risk patient and this low risk procedure is not expected to require hospitalization that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for acute inpatient hospital care associated with an already approved elective surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 85060 provided on March 12, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 85060 is blood smear, peripheral, interpretation by physician with written report.
We find that CPT code 85060 is not supported in the medical record. Specifically, the documentation did not contain a signed physician order. There are no authenticated medical records from the ordering provider documenting the treating physician had intended the clinical diagnostic test be performed. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 85060 provided on March 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 codes 81295, 81298, 81317, 81401, 81403, 81162 and 81403 are not supported in the
medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of
the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was
obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim
history indicates that the specimen was obtained in an office setting place of service 11. Based on this
information, we decided that Medicare rules for coverage of the laboratory services have not been met.
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on July 9, 2020.