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

We decided that the Plan has to pre-approve a high frequency chest wall oscillation device (HFCWOD).

You asked the Plan to pre-approve a HFCWOD. You say that this device is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says that this device is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.

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 HFCWOD. Our reviewer says that this device is medically reasonable and necessary. Our physician reviewer found this patient has COPD and chronic mycobacterium avium complex infection, with a chronic productive cough and frequent exacerbations requiring antibiotics. Although the radiologist's report of the most recent chest computed tomography (CT) scan does not mention bronchiectasis, the pulmonologist clearly attests to the presence of bronchiectasis on the CT, having personally reviewed it. Chronic MAC infection is consistent with bronchiectasis. A HFCWOD is therefore considered reasonable and medically necessary for this patient.

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 HFCWOD have been met. Therefore, we decided that the Plan has to pre-approve a high frequency chest wall oscillation device (HFCWOD).

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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar interlaminar epidural steroid injection to be
provided by you.

You asked the Plan to pre-approve the lumbar interlaminar epidural steroid injection. The Plan denied your
request. The Plan says the enrollee must receive care from in-network providers with the exception of
emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior
authorization from the Plan.

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 pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve a lumbar
interlaminar epidural steroid injection to be provided by you.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on November 6, 2020.
You asked the Plan to pay for the outpatient clinic visit. You say that the care provided was medically necessary and consistent with standard of medical practice based on the enrollee's condition. You say that the claim should be considered for reimbursement. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the outpatient clinic visit provided by an out-of-network provider on November 6, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met at a lower level of care, such as long-term care.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.

You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been 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 enrollee is a 75-year-old female who was admitted to an acute care hospital on
April 14, 2021, for an infected kidney stone. The enrollee does not require the intensity of services provided at
an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation. The enrollee's care needs can be met 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 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 laboratory services provided by an out-of-network provider on December 12, 2020.
You asked the Plan to pay for laboratory services. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on December 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 14301, CPT 14302) provided on November 2, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed codes cannot be verified.
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 14301 is "Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm". The CPT Code Manual definition of code 14302 is "Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure)". 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 use of CPT codes 14301 and 14302 is not supported by the records provided. Our coding reviewer found that the operative report documents, "At this point it was necessary to combine and divide the septate areas between the Swiss cheese like fascial defects and it was necessary to perform myofascial advancement flaps by freeing up the posterior rectus sheath and creating advancement flaps towards the midline measuring 100cm2." The operative report does not include enough documentation to confirm that sections of healthy tissue were transferred or transplanted to the area adjacent to the defect. Therefore, this procedure 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 the services (CPT 14301, CPT 14302) provided on November 2, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 14 additional occupational therapy (OT) visits.
You asked the Plan to pre-approve the additional visits. The Plan denied your request. The Plan says additional visits 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 the additional visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health plan without assessment of the response to prior authorized therapy. The enrollee has had prior therapy approved and without evidence of outcome of this therapy, the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a therapist. The enrollee was authorized 10 visits to include a home exercise program. The requested services are not part of a maintenance program. 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 14 additional occupational therapy (OT) visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625x2).
You asked the Plan to pre-approve radiofrequency ablation. You say that the enrollee's clinical records are attached to show she has received relief with past injections. The Plan denied your request. The Plan says this service is not considered medically necessary as research has not proven to be helpful.
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 radiofrequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy reported in the peer reviewed literature. Therefore, the request is considered 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 radiofrequency ablation have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation, nerves innervating the sacroiliac joint (64625x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the oxygen concentrator and portable oxygen system provided on November 8, 2020 and December 8, 2020.
You asked the Plan to reduce the coinsurance for the oxygen concentrator and portable oxygen system. You say that you were not notified the provider is out-of-network. You say that you were only charged $36.40 a month before this changed to out-of-network. The Plan denied your request. The Plan says the out-of-network coinsurance applied correctly.
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 40% coinsurance for durable medical equipment from an out-of-network provider. You have been asked to pay a total of $140.40 for the oxygen concentrator and portable oxygen system.
The oxygen concentrator and portable oxygen system fall within the "Durable medical equipment (DME) and related supplies" 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 reduce the coinsurance for the oxygen concentrator and portable oxygen system provided on November 8, 2020 and December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous glucose monitor provided on September 17, 2020.
You asked the Plan to pay for the provided monitor. The Plan denied your request. The Plan says the documentation did not indicate the provider discussed the need for the provided services.
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 medical records do not indicate that the enrollee 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. Based on this information, we decided that Medicare rules for coverage of the provided monitor have not been met. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor provided on September 17, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pulp vitality tests (D0460) and bitewing - single radiographic image (D0270) provided November 18, 2020.
You asked the Plan to pay for the pulp vitality tests and bitewing x-ray. You say that the services were necessary and should be covered. The Plan denied your request. The Plan says you met frequency limits for x-rays and the pulp vitality tests are 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. We looked at the file, and Medicare rules. The Plan provided documentation showing that coverage for bite-wing x-rays was previously provided in the same year. Though the Plan offers a dental benefit in excess of Medicare coverage, the pulp vitality tests are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the pulp vitality tests (D0460) and bitewing - single radiographic image (D0270) provided November 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair transit option.

You asked the Plan to pre-approve a power wheelchair transit option (K0108). You say that the enrollee needs
a power wheelchair and accessories. The Plan denied your request. The Plan says the transit option is a nonmedical
feature that is intended for use outside the home.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use
inside the home.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Also, the item at
issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the
Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve
a Group 3 power wheelchair transit option.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (97110) provided on September 16, 2019.

You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the chiropractic services (97110) provided on September 16, 2019.
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. You say that LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care at this time and LTACH care is not 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 the enrollee is a 78-year-old female who was admitted to the acute care hospital (ACH) on April 10, 2021, with shortness of breath. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight (8) physical therapy visits (CPT code 97110), for
the enrollee.
You asked the Plan to pre-approve the physical therapy visits. You say that the provider would like the enrollee
to continue to strengthen and improve cardiovascular conditioning due to post COVID-19 diagnosis. The Plan
denied your request. The Plan says this level of therapy is no longer showing progression.
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 the physical therapy visits. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally
accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health
plan. The enrollee has had extensive prior therapy and the records do not demonstrate that the unique skills of a
professional therapist are required to safely and effectively provide treatment, or that the services can be safely
and effectively performed only by a therapist, or for physical therapy, by or under the supervision of a
therapist. The enrollee has been authorized two (2) sessions to ensure instruction in a home exercise program.
The requested services are not part of a maintenance program, are the specialized skill, knowledge and
judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the
enrollee's current condition or to prevent or slow further deterioration.
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 physical therapy visits have not been met. Therefore, we decided that the
Plan does not have to pre-approve eight (8) physical therapy visits (CPT code 97110), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.

You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that you do not qualify for a 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 and attachments.