Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility or home with home health care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 an infection of the left foot and had a left below the knee amputation. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is
no documented need for intensive rehabilitation services. Medically necessary care 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air purifier.

You asked the Plan to pre-approve an air purifier. You say that you require the requested item as a prophylactic measure. The Plan denied your request. The Plan says rules for durable medical equipment have not been met.

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 an air purifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).

You asked the Plan to pre-approve this device. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this item is not medically necessary.

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 this device. Our reviewer says that the requested item is not considered medically reasonable and necessary in this case. Our physician reviewer found that based on the medical records provided and the current medical literature there is no documentation provided that indicates the robotic upper extremity range of motion assist device at issue in this case is medically reasonable and necessary. Current guidelines consider robotic therapy of "uncertain utility compared with dose-matched conventional upper limb exercise therapies."

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this device have not been met. Therefore, we decided that the Plan does not have to pre-approve a powered upper extremity range of motion assist device (L8702).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that the enrollee is a diabetic. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FlowerAminoFlo (Q4177).

You asked the Plan to pre-approve FlowerAminoFlo. You say that this is medically necessary. The Plan denied
your request. The Plan says this is not covered for the enrollee's condition, tarsal tunnel syndrome.

The Plan must follow Medicare rules. Medicare rules say that Autologous Stem Cell Transplantation (AuSCT)
is considered reasonable and necessary in the circumstances described in the NCD.

We looked at the file and Medicare rules. The limited records provided do not show that the enrollee has a
covered condition for the requested FlowerAminoFlo. Based on this information, we decided that Medicare
rules for coverage of FlowerAminoFlo have not been met. Therefore, we decided that the Plan does not have to
pre-approve FlowerAminoFlo (Q4177).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be received 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. 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 carotid artery surgery after a recent stroke. Medical problems 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. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a hearing exam (92550) to be provided by an OON
provider.

You asked the Plan to pre-approve an OON hearing exam. You say that your appointment with an in-network
provider was canceled. The Plan denied your request. The Plan says this is available in-network.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
routine hearing services and hearing aids only when they are provided in-network.

We looked at this physician's review, the file, and the Plan's rules. The provider you are requesting is out-of-network
with the Plan. Based on this information, we decided that the Plan's rules for coverage of a hearing
exam have not been met. Therefore, we decided that the Plan does not have to pre-approve a hearing exam
(92550) to be provided by an OON provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 35 hours of home health services per week.

You asked the Plan to pre-approve the home health services. You say that the requested services are necessary. The Plan denied your request. The Plan says the requested services are not reasonable and necessary. The Plan also says that an hourly home health aide for 140 hours per month would be considered custodial care which is excluded from coverage.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 home health services. Our reviewer says that 35 hours of home health services per week is not medically necessary. Our physician reviewer found the provided documentation does not show that skilled nursing services are required to effectively provide treatment, care, or services in order to improve your condition, or to perform a maintenance program to maintain your condition or prevent deterioration. The reviewer found that the provided documentation is insufficient to demonstrate that skilled therapy services are currently required to effectively provide treatment, care, or services in order to improve your level of function, or to perform a maintenance program to maintain your level of function or prevent deterioration. Therefore, the reviewer found that the requested services are not medically reasonable or 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 home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 35 hours of home health services per week.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced (K3) foot and advanced microprocessor knee.

You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says your medical history and use of walker prior to amputation are inconsistent with a K3 ambulatory function.

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 requested items. Our physician reviewer found that prior to the amputation, you used a walker and were able to exercise, drive and accomplish self-care tasks and shopping. Your current functional level is a K2, but you are expecting to reach a K3 functional level with rehabilitation. The request is for a leg prosthesis that has an advanced foot/knee for uneven terrain and with variable cadence. A level 3 ambulator has the ability or potential for ambulation with variable cadence. A K3 amputee has the ability or potential for ambulation with variable cadence. They have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. In this case, the documentation supports that you are deconditioned and have not been able to exercise. The approved prosthesis will accomplish walking, navigating stairs and basic exercise. The documentation does not support that you require an advanced K3 foot with advanced microprocessor. 

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 requested items have not been met. Therefore, we decided that the Plan does not have to pre-approve an advanced (K3) foot and advanced microprocessor knee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.

You asked the Plan to pre-approve a Vertiflex Superion Interspinous device. You say that the services are
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore,
coverage criteria have not been met.

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 a Vertiflex Superion Interspinous
device. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is
needed to show safety and efficacy.

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 Vertiflex Superion Interspinous device have not been met. Therefore, we
decided that the Plan does not have to pre-approve a Vertiflex Superion Interspinous device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on November 30, 2020.

You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does 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 G0483 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; 22 or more drug class(es), including metabolite(s) if performed.

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 drug testing services. Our reviewer says that CPT code G0483 does not meet criteria for billing or reimbursement consideration. Our reviewer found the laboratory report supports 16 drug classes, therefore, HCPCS G0482 would be the appropriate code to report in this case. 

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 drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOneCDx (F1CDx) testing provided on September 23, 2020.

You asked the Plan to pay for the FoundationOneCDx (F1CDx) testing. You say that the FoundationOneCDx (F1CDx) testing provided on September 23, 2020 was medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the FoundationOneCDx (F1CDx) testing provided on September 23, 2020.

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 pay for the FoundationOneCDx (F1CDx) testing. Our reviewer says that the enrollee does not meet criteria for the FoundationOneCDx (F1CDx) testing provided on September 23, 2020. Our physician reviewer found the enrollee had F1CDx testing on September 23, 2020 and is diagnosed with malignant neoplasm of upper lobe, right bronchus or lung. Molecular testing is for stage III and IV disease.

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 FoundationOneCDx (F1CDx) testing have not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOneCDx (F1CDx) testing provided on September 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
You asked the Plan to pre-approve a complete upper denture. You say that the dentures are medically necessary, and you would like them to be covered. The Plan denied your request. The Plan says dentures are not covered under your dental 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 pre-approve a complete denture - maxillary (D5110).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.

You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 left sided weakness. Medical problems 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 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: 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 the SNF admission. You say that it is felt that SNF services are medically required. The Plan denied your request. The Plan says you no longer need daily skilled services. Your needs are custodial at this time.

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 the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a 77-year-old woman with a history of hypertension and multiple sclerosis, who was admitted to the hospital on 4/14/21 with a stroke. The enrollee has received SNF services. In a Functional Skills Assessment, it is documented that the enrollee was maximum assist for bed mobility, transfers, self-feeding, bathing, toileting, and upper and lower body dressing. The enrollee is unable to communicate pain. No required skilled nursing services are identified. While the enrollee may benefit from additional skilled therapy services, the documentation does not support that the enrollee now requires these services on a daily basis on an inpatient basis in a skilled nursing facility. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF admission 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that your foot hurts bad. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.