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

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with multiple power
options for the enrollee.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied
your request. The Plan says the criteria would be met for a power wheelchair with no power options.
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 the wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the requested
wheelchair would exceed the enrollee's needs.
The enrollee does not use a ventilator mounted to the wheelchair and does not meet coverage criteria for a
power tilt and power recline seating system. There is no evidence of intermittent catheterization, spasticity, or
evidence of being high risk for a pressure ulcer. The documentation does not reveal that the patient requires
other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control,
head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not
need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for
alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer
through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper
extremities with the ability to feed herself supports that the enrollee can control any power options through
their own individual switches.
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 wheelchair have not been met. Therefore, we decided that the Plan does not
have to pre-approve a group 3 power wheelchair with multiple power options for the enrollee
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her baseline. It has not yet been established that the enrollee has reached a new plateau in function. The enrollee has had some improvement in her National Institutes of Health Stroke Scale (NIHSS), making a trial of skilled therapy reasonable. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's condition. The enrollee's care needs, as a practical matter, cannot be provided at a lower level of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
You asked the Plan to pre-approve genicular nerve RFA. You say that this is medically necessary, and the enrollee had a prior genicular nerve block with some relief from pain. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is still being studied for the treatment of chronic pain after total knee arthroplasty.
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 genicular nerve RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the role of genicular nerve blocks after total knee arthroplasty is still uncertain. This procedure is considered experimental/investigational.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular nerve RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (RFA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy with meniscectomy surgery.

You asked the Plan to pre-approve knee surgery. You say that the Plan's reason for denial is not justified. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure has not been shown to be superior to conservative management and carries significantly higher risks.

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 knee surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of an adequate trial of physical therapy for knee pain. Surgery is not needed 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 knee surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy with meniscectomy surgery.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve fluorescent in situ hybridization (FISH) genetic testing services.
You asked the Plan to pre-approve the FISH genetic testing services. You say that the records provided support the need for the genetic testing services being requested. The Plan denied your request. The Plan says the genetic testing services which remain in dispute are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that FISH testing is indicated in the evaluation of patients whose bone marrow examination is suggestive of MDS and who have had a failed or inadequate cytogenetic assessment. 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 FISH genetic testing services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support that a bone marrow examination is suggestive of myelodysplasia, and the enrollee has not had a failed or inadequate cytogenic assessment. 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 FISH genetic testing services have not been met. Therefore, we decided that the Plan does not have to pre-approve fluorescent in situ hybridization (FISH) genetic testing services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the WATS 3D biopsy testing provided on November 19, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says that this is not medically necessary.
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 pay for the testing. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that The American Society of Gastrointestinal Endoscopy suggests using WATS-3D (brush) biopsy testing in patients with known or suspected Barrett's esophagus. The available clinical documentation in the case file supports that the enrollee in this case has Barrett's esophagus with low-grade dysplasia. The documentation supports that the WATS 3D biopsy testing was medically reasonable and necessary for this enrollee. 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 testing have been met. Therefore, we decided that the Plan has to pay for the WATS 3D biopsy testing provided on November 19, 2020.
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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration (96401) and Denosumab injection (J0897) provided October 22, 2020.
You asked the Plan to pay for the chemotherapy administration and Denosumab injection. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says the medical records do not support the services 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. In this case, the CPT Code Manual definition of code J0897 is Denosumab injection and 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic.
We asked our coder 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 chemotherapy administration and Denosumab injection. Our reviewer says that the medical documentation does not support the services as billed. Our physician reviewer found the medical records provided do not include sufficient documentation to validate that a Denosumab injections (60 units) was performed on October 22, 2020, therefore this service cannot be verified. In addition, the medical records provided do not include sufficient documentation to validate that a chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic was performed on October 22, 2020, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration and Denosumab injection have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration (96401) and Denosumab injection (J0897) provided October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for 135 units of code 00840 provided on May 20, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the records do not support 135 units billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 

We asked our coding 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 records provided do not support 135 units of code 00840. Our coding reviewer found that the procedure report does not support 9 hours of anesthesia time, and therefore would not be covered. Anesthesia start and end time is not clearly documented and cannot be confirmed as performed.

We looked at this coder'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 pay for 135 units of code 00840 provided on May 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 that you do not have documented skilled nursing needs. In addition, you do not have documented skilled therapy needs. You are consistently ambulating more than 100 feet and tending to activities of daily living with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on September 14, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the services provided by an out-of-network provider on
September 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure (97110) provided January 21, 2021.

You asked the Plan to pay for the therapeutic procedure. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says there is a more appropriate code for the services performed than what was 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.

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 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 therapeutic procedure. Our reviewer says that the requested service as billed is not supported by the medical records. Our physician reviewer found the medical records document that service was performed in Place of Service 12, in the patient's home. 97110 is not the most appropriate Healthcare Common Procedure Coding System code to use to bill this service, therefore, this service is not eligible for reimbursement consideration.

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 therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure (97110) provided January 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care continues to be medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.
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 beneficiary is an 89-year-old male with seizure disorder and hypertension admitted to the hospital with lethargy and acute metabolic encephalopathy. Although the enrollee has identifiable skilled nursing service needs, there are no identifiable skilled therapy service needs. In addition, the enrollee does not require skilled nursing or therapy services on a daily basis. In conclusion, the enrollee 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that you would like an IRF admission for more intense therapy to return to your former independence. The Plan denied your request. The Plan says IRF care is not medically necessary. Therapy needs are being met at the current facility.
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 that 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.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 2, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on February 2, 2021.