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

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says 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 above 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 you are now mostly minimal assist-to-supervised for all care. You have no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care (including home health care services or placement at a custodial center). Your vital signs are stable and you are tolerating an oral diet. SNF is not medically necessary.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-approveskilled nursing facility (SNF) care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durezol 0.05% eye drops.
You asked the Plan to pre-approve the eye drops. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
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 Durezol 0.05% eye drops.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism.You asked the Plan to pre-approvea seat lift mechanism. You say that you need a replacement chair lift so you will be able to get up from a sitting position.The Plan denied your request. The Plan says there is no indication in the clinical information that you are completely incapable of standing up from a regular arm chair.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.We looked at the file and Medicare rules. The documentation does not support that you are completely incapable of standing from a regular chair. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met.Therefore, we decided that the Plan does not have to pre-approvea seat lift mechanism
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forferric carboxymaltose injections (J1439) provided on March 17, 2020 through March 24, 2020.You asked the Plan to waive the coinsurance forthe ferric carboxymaltose injections. You say that you would like reconsideration because you have never been charged a copayment for these injections in the past.The Plan denied your request. The Plan says the 20% coinsurance has been billed in accordance to the 2020 Evidence of Coverage.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 20% coinsurance for Medicare Part B Prescription Drugs. You have been asked to pay $166.50 for the ferric carboxymaltose injections. The allowed amount for this service is $832.50. $832.50x.2 = $166.50. You have been asked to pay the correct amount for this service.You have been asked to pay 20% coinsurance for the ferric carboxymaltose injections. The ferric carboxymaltose injections falls within the Medicare Part B Prescription Drugs benefit category. 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 waive the coinsurance forferric carboxymaltose injections (J1439)provided on March 17, 2020 through March 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea home ventilator for the enrollee.You asked the Plan to pre-approvea home ventilator. You say that this is medically necessary.The Plan denied your request. The Plan says that records do not show that the enrollee has ongoing breathing failure.The Plan must follow Medicare rules. The rules say that ventilators may becovered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.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 a home ventilator. Our reviewer says that a home ventilator is not medically reasonable and necessary for the enrollee in this case. The enrollee is noted to have COPD.There is no evidence that the enrollee has a neuromuscular disorder or a restrictive thoracic disease. While the enrollee is noted to have had a ventilator since 2017, it appears that the enrollee may be using it as a BiPAP machine. Furthermore, there is no log of how compliant the enrollee is with using her device. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for a home ventilator.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a home ventilator have not been met.Therefore, we decided that the Plan does not have to pre-approvea home ventilator for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 95957 provided on November 4, 2019.You asked the Plan to pay for CPT code 95957. You say that the medical records support the billing of CPT code 95957.The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 95957.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 95957 is Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). 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 CPT code 95957. Our reviewer says that the medical records do not support the billing of CPT code 95957. Our physician reviewer found documentation does not include a digital analysis of electroencephalogram.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 95957 have not been met.Therefore, we decided that the Plan does not have to pay for CPT code 95957 provided on November 4, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a full night titration study for the enrollee.
You asked the Plan to pre-approve the study. You say that this is medically necessary. The Plan denied your
request. The Plan says titration can be done at home, using an auto-titrating PAP machine.
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 study. Our reviewer says that the
requested study is not considered medically reasonable and necessary in this case. Our physician reviewer
found the enrollee has obstructive sleep apnea diagnosed on recent diagnostic polysomnography (PSG). An inlab
full night PAP titration study has been ordered. The enrollee's needs could be met with a trial of autotitrating
CPAP (APAP) at home. This is less expensive and more convenient for the patient. The medical
records do not indicate any contraindications for APAP. Therefore an attended PSG for PAP titration is
considered not medically necessary.
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 study have not been met. Therefore, we decided that the Plan does not have
to pre-approve a full night titration study for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral genicular nerve blocks.
You asked the Plan to pre-approve bilateral genicular nerve blocks. You say that your physician told you nerve blockers will be the only thing that can help your pain. The Plan denied your request. The Plan says that there is little medical evidence that shows this type of nerve block is helpful and safe.
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 bilateral genicular nerve blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The effectiveness of genicular nerve blocks to treat knee pain has not been established. Genicular nerve blocks are considered experimental/investigational in nature. Our physician reviewer found that your condition does not meet criteria for bilateral genicular nerve blocks. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bilateral genicular nerve blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral genicular nerve blocks.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transfer bench.You asked the Plan to pre-approvea transfer bench. You say that a transfer bench is the safest way to bathe and toilet the enrollee.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that transfer benches are not covered because they are not primarily medical in nature. While a transfer bench may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea transfer bench.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve a group 3 power wheelchair. You say that the requested group 3 power
wheelchair is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare
criteria for the requested group 3 power wheelchair.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3
power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on February 5, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says CurrentProcedural Terminology (CPT) code 80307 and Healthcare Common Procedure Coding System (HCPCS) code G0483 remain 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 the denied codes is:CPT 80307:Drug test(s), presumptive, any number of drug classes, any number of devices or procedures; by instrument chemistry analyzers (eg, utilizing immunoassay [eg, EIA, ELISA, EMIT, FPIA, IA, KIMS, RIA]), chromatography (eg, GC, HPLC), and mass spectrometry either with or without chromatography, (eg, DART, DESI, GC-MS, GC-MS/MS, LC-MS, LC-MS/MS, LDTD, MALDI, TOF) includes sample validation when performed, per date of service.HCPCS G0483: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; 22 or more drug class(es), including metabolite(s) if performed. 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 coded correctly. Our physician reviewer found based on the medical records provided the documentation does not support the coding of HCPCS G0483 and CPT 80307.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 pay fordrug testing services (CPT 80307 and HCPCS G0483) provided to the enrollee on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower/bath chair.
You asked the Plan to pre-approve a shower/bath chair. You say that this item is medically necessary. The Plan
denied your request. The Plan says this item is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower/bath chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says the enrollee does not have a complex medical need that requires close supervision, or the need to participate in at least three hours of therapy per day.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 physician reviewer found that the enrollee is at supervision to standby assist for mobility. She is independent to standby assist for activities of daily living. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. She may benefit from, physical and occupational therapy, but the documentation does not support that the enrollee's functional status requires an 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a non-electronic spirometer.
You asked the Plan to pre-approve a non-electronic spirometer. You say that you need a spirometer The Plan
denied your request. The Plan says a spirometer does not meet the definition of durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must meet the
definition of a DME.
The item at issue in this appeal is not covered by Medicare or the Plan. Therefore, we decided that the Plan
does not have to pre-approve a non-electronic spirometer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansayscare could be received in another setting.The Plan mustfollow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif 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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care (ex. SNF/SAR).We lookedat 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve 10 additional physical therapy (PT) visits.
You asked the Plan to pre-approve these services. You say that the enrollee has had a decline in functional
status. 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 medically necessary outpatient
therapy.
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 Parkinson's disease and
repeated falls. A decline in transfers and ambulation is reported. The note on June 30, 2020 states his Dynamic
Gait Index/Total Score indicated severe impairment and his Elderly Mobility Scale had declined. The requested
therapy is generally accepted as specific and effective therapy for the enrollee's condition. The enrollee requires
the unique skills of a professional therapist to safely and effectively provide treatment. The requested 10
additional PT visits are reasonable and medically necessary.
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 preapprove
10 additional physical therapy (PT) visits.
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-approvepercutaneous laminotomy/laminectomy for decompression (MILD procedure).You asked the Plan to pre-approveMILD procedure. You say that the enrollee is eligible for coverage according to the Medicare-approved Coverage with Evidence Development (CED) study.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the records do not show that all conservative treatment options have been tried.The Plan follows Medicare rules. Medicare rules say that the MILD procedure is covered by Medicare through a Medicare-approved CED study, and that the Plan is responsible for payment of items and services in Medicare-approved CED studies unlessMedicare determines otherwise.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 MILD procedure. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested MILD procedure. Our physician reviewer found the enrollee is not enrolled in a clinical trial. This request does not meet the Medicare criteria. The requested MILD procedure is not medically reasonable and necessary for the 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 MILD procedure have not been met. Therefore, we decided that the Plan does not have to pre-approvepercutaneous laminotomy/laminectomy for decompression (MILD procedure).