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

We decided that the Plan does not have to pre-approve SNF care, for the enrollee.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not meet CMS coverage criteria for an SNF admission. The enrollee does not have daily nursing needs and there is no change in function from base line that needs daily skilled therapy services in an SNF. Assistance for activities of daily living (ADL) tasks and transfers may be provided by unskilled persons and does not require the hands-on assistance of licensed therapists. This enrollee would be equally well served at an alternative level of care such as a long-term care facility. Since home discharge is not possible, the enrollee requires a long-term care (LTC) facility placement with intermittent therapies. Hence, the enrollee needs are at a level of LTC and not an admission to an SNF with daily physical therapy (PT), speech and occupational therapy (OT) and nursing care. The enrollee's needs are at a custodial care level. There is no documented evidence of need for an intensive therapy program with therapy daily in an inpatient setting as in an SNF.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care, for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 22867), for the enrollee.

You asked the Plan to pre-approve the service. You say that the enrollee has new and worsening conditions. You state the enrollee has moderate severe stenosis L3-L4 lesser at L2-L3 and L4-L5, left L5-S1 disc herniation/disc osteophyte complex, moderate multi-level disc herniation and disc degeneration thoracolumbar spine multi-level. The Plan denied your request. The Plan says there are not enough scientific studies to show that inserting a device to open the narrowed space would be safe and effective for the enrollee.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the interlaminar device remains experimental. More research is needed to show safety and efficacy of the 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 the service have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level (CPT code 22867), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test coded G0481 provided on October 30, 2020.

You asked the Plan to pay for the drug test. 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 G0481 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 8-14 drug class(es), including metabolite(s) if performed.

We find that CPT code G0481 is 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 outpatient rehabilitation setting place of service 57. Based on this information, we decided that Medicare rules for coverage of the drug test have not been met. Therefore, we decided that the Plan does not have to pay for the drug test coded G0481 provided on October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve osteogenesis stimulator, low intensity ultrasound, non-invasive (CPT code E0760), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the DME is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 DME. Our physician reviewer found the review indicates that the enrollee is status post internal fixation of her recurrent right fifth metatarsal proximal metadiaphyseal stress fracture using medullary screw fixation and right proximal tibial bone marrow aspirate and right fifth metatarsal head lateral exostectomy and soft tissue bunionette correction on May 27, 2021. Foot Exogen bone stimulator is recommended to aid in healing of the enrollee's recurrent fracture. However, criteria the is not met due to imaging not appearing to show significant evidence of fracture healing versus nonhealing that are 90 days apart. The medical records provided do not meet the requirements listed in the LCD for Medicare 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 the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve osteogenesis stimulator, low intensity ultrasound, non-invasive (CPT code E0760), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6535.

You asked the Plan to pre-approve the compression stockings. You say that you have paralysis, and you need these stockings to prevent blood clots. You are afraid that your condition and the risk of having blood clots would affect your memory. The Plan denied your request. The Plan says these dressings are non-covered under the surgical dressing benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6535 are noncovered because they do not meet the statutory definition of a surgical dressing. 

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6535.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.

You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that this item is
medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for
coverage of this device have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically
reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per
day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based
on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have
to pre-approve a therapeutic continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on January 6,
2021.

You asked the Plan to pay for the therapeutic activities. 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 97530 is therapeutic activities, direct (one-on-one)
patient contact (use of dynamic activities to improve functional performance), each 15 minutes.

We find that CPT code 97530 is not supported in the medical record. Specifically, the documentation shows
that these services were performed by an occupational therapist assistant in a home health or hospice setting.

This means there is a more appropriate code to be billed for the services provided. Based on this information, we decided that Medicare rules for coverage of the therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic activities coded 97530 provided on January 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on July 3, 2020.

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 97110 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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 

We find that CPT code 97110 is not supported in the medical record. Specifically, the records show that the services were performed in the home setting and there is a more appropriate code for these services. 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 the physical therapy services rendered on July 3, 2020.
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. The Plan denied your request. The Plan says LTACH admission 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 that the enrollee was admitted with hypoxic respiratory failure. The record indicates that the enrollee has increased lung consolidations and possible bowel obstruction. The enrollee continues to receive acute care services. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that IRF admission is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.

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 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 femoral fracture after a fall. 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. 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide an additional 24 one-way routine transportation trips.

You asked the Plan to provide additional routine transportation. You say that you cannot drive due to a medical condition, and this transportation is necessary for you to get to your doctor's appointments. The Plan denied your request. The Plan says 24 routine transportation trips may be covered per year. This benefit does not include trips in excess of this amount.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the request for additional trips exceeds the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide an additional 24 one-way routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).
You asked the Plan to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962). You say that the enrollee's current prosthesis is worn and de-laminated. The Plan denied your request. The Plan says protection of prosthetic components can be achieved with the cover (L5704) that has been approved.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The record does not show the enrollee will need protection against unusually harsh environmental situations. Based on this information, we decided that Medicare rules for coverage of addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962) have not been met. Therefore, we decided that the Plan does not have to pre-approve addition, endoskeletal system, below knee, flexible protective outer surface covering system (L5962).
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for weakness and polyneuropathy. Your 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. Our physician reviewer found that your 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute 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 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 respiratory failure, pneumonia and a urinary tract infection. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for incomplete endodontic therapy (D3332) provided on February 8, 2021.
You asked the Plan to pay for incomplete endodontic therapy. You say that you want the Plan to pay for the service. The Plan denied your request. The Plan says the service at issue is not a covered benefit.
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 incomplete endodontic therapy (D3332) provided on February 8, 2021.