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

We decided that the Plan does not have to pre-approve continued inpatient psychiatric care.

You asked the Plan to pre-approve the continued inpatient psychiatric care. You say that it is felt that ongoing
inpatient care is required. The Plan denied your request. The Plan says you are no longer receiving active
treatment, and as such, the services cannot be covered by Medicare.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 continued inpatient psychiatric care.
Our reviewer says that the documentation does not support that the criteria for inpatient psychiatric care are
met beyond the date in question. Our physician reviewer found the enrollee was admitted involuntarily due to
aggression and a psychotic episode. The record indicates that the enrollee is cooperative, taking medications 
and, although confused due to neurocognitive issues, is not aggressive, suicidal, or homicidal. 
The record indicates the enrollee is awaiting placement. In this case, the record indicates that the enrollee 
was at her baseline level of functioning with no reasonable expectation of further improvement. 
Therefore, the treatment cannot be considered active and coverage for the inpatient stay cannot be recommended.

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 continued inpatient psychiatric care have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the group 1 power operated vehicle.

You asked the Plan to pre-approve the group 1 power operated vehicle. You say that this device is medically
necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for a power
operated vehicle have not been met.

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.

The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that
Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to
pre-approve the group 1 power operated vehicle.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the abductor (wedge) pillow (E1399).

You asked the Plan to pre-approve the abductor (wedge) pillow. You say that this is necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not a covered service as it is a personal comfort item.

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 the abductor (wedge) pillow (E1399).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300).

You asked the Plan to pre-approve the power seat elevation system. You say that this service is necessary for
your condition. The Plan denied your request. The Plan says Medicare does not cover this item.

The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature (E2300) is noncovered
because it is not primarily medical in nature.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not
have to pre-approve the power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous supplies for the implanted heart device.

You asked the Plan to pre-approve miscellaneous supplies for the implanted heart 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 miscellaneous supplies for the implanted heart device. 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 evidence to support that the requested supplies, in the form of a pre-packaged left ventricular assist device (LVAD) care kit, are medically necessary and reasonable.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of miscellaneous supplies for the implanted heart device have not been met. Therefore, we decided that the Plan does not have to pre-approve miscellaneous supplies for the implanted heart device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services.

You asked the Plan to pre-approve the continued SNF care. You say that you feel that you continue to require wound care and other services in the SNF setting. The Plan denied your request. The Plan says you no longer require skilled nursing or therapy services on a daily basis.

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 continued SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is a female who presented to the hospital with cellulitis of both legs. She was treated in the hospital with antibiotics and improved and transferred to a skilled nursing facility for skilled nursing and therapy services. She was treated in the skilled nursing facility with nursing care and physical and occupational therapy for lower extremity cellulitis, wounds (stasis ulcers) and weakness. She is walking 100 feet with a rolling walker with contact guard assistance and is contact guard assist for transfers and activities of daily living. She is reported to be medically stable; her antibiotics were reportedly stopped. Continued care in the skilled nursing facility or skilled nursing and therapy services is requested.

The records provided do not support that the enrollee requires skilled nursing or skilled therapy services, i.e., the specialized skill, knowledge and judgment of a skilled professional nurse/qualified therapist is not required to safely and effectively provide medically necessary and reasonable treatment. Based on the medical records provided, this patient does not require the services on an inpatient basis, only 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 continued SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient level of care for the approved surgery.

You asked the Plan to pre-approve inpatient level of care for the approved surgery. You say that the inpatient level of care for the approved surgery is medically necessary. The Plan denied your request. The Plan says the inpatient level of care for the approved surgery 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 inpatient level of care for the approved surgery. Our reviewer says that the inpatient level of care for the approved surgery is not medically necessary. Our physician reviewer found in this case; the documentation provided indicates that the enrollee has stable medical conditions. There is no evidence of unstable medical conditions or any unique characteristics that would require a prior inpatient admission. Therefore, the requested prospective inpatient admission cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient level of care for the approved surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient level of care for the approved surgery.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for x-ray transportation and set up (R0070, Q0092).

You asked the Plan to pay for x-ray transportation and set up. You say that this should be covered. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that when a skilled nursing facility (SNF) resident receives a portable x-ray service during the course of a Medicare-covered stay in the SNF, only the service's professional component is a separately billable physician service under Part B. By contrast, the technical component representing the procedure itself, including any associated transportation and setup costs, would be subject to consolidated billing, and must be included on the SNF's Part A bill for the resident's covered stay. The rules also say that Place of Service (POS) code 31 should be used with services for patients in a Part A covered skilled nursing facility stay.

We looked at the file and Medicare rules. The services at issue were billed with POS 31, indicating that the enrollee was an SNF resident. Technical components, including transportation and setup costs, are not separately billable from the SNF stay. Based on this information, we decided that Medicare rules for coverage of x-ray transportation and set up have not been met. Therefore, we decided that the Plan does not have to pay for x-ray transportation and set up (R0070, Q0092).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa 1g capsules.

You asked the Plan to pre-approve the Vascepa capsules. You say that this drug is needed due to the enrollee's
high lipids and triglycerides. The Plan denied your request. The Plan says this oral drug is not covered by
Medicare Part B.

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 Vascepa 1g capsules.

Benefits for the Vascepa capsules may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an initial preventive exam (G0402) and an outpatient clinic visit (G0463).

You asked the Plan to pay for an initial preventive exam and an outpatient clinic visit. You say that these services should be covered. The Plan denied your request. The Plan says these services cannot be billed together without appropriate modifiers.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that many procedure codes cannot be reported together because they are mutually exclusive of each other. Mutually exclusive procedures cannot reasonably be performed at the same anatomic site or same patient encounter.

In this case, the CPT Code Manual definition of code G0402 is initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of Medicare enrollment and G0463 is hospital outpatient clinic visit for assessment and management of a patient.

We find that CPT codes G0402 and G0463 are not supported in the medical record. Specifically, G0402 is not supported because at the time of service, the enrollee was not a new beneficiary in her first 12 months of Medicare enrollment. CPT G0463 is not supported because it is a mutually exclusive procedure to G0402 and these procedures cannot be reported together. Based on this information, we decided that Medicare rules for coverage of an initial preventive exam and an outpatient clinic visit have not been met. Therefore, we decided that the Plan does not have to pay for an initial preventive exam (G0402) and an outpatient clinic visit (G0463).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services.

You asked the Plan to pay for the acupuncture services. You say that you were told the services were covered. The Plan denied your request. The Plan says the services are not a covered benefit.

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.

Although Medicare covers acupuncture under certain medical indications, the provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services. 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 acupuncture services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant tablet 600mg.

You asked the Plan to pre-approve Horizant. You say that the drug is medically necessary. The Plan denied your request. The Plan says the drug is not covered under the member's plan.

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 Horizant tablet 600mg.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.

You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the enrollee has not tried and failed Orthovisc and Monovisc.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Gelsyn-3. Our physician reviewer found that you have pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. You have failed conservative treatment. Gelsyn-3 injections have been requested. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. You have not tried and failed the required drugs. There is no indication that the plan's required drugs would likely be less effective, or likely have adverse effects.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration (20939) for bone grafting.

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service 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 service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that a bone marrow aspirate remains experimental in cases of spinal fusion. More research is needed. An Iliac crest bone graft remains the gold standard for bone grafting. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration (20939) for bone grafting.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided by the out-of-network provider.

You asked the Plan to pre-approve physician's services. The Plan denied your request. The Plan says you must receive care from a network provider and in most cases, care received from an out-of-network provider will not be covered, except for emergency care or urgently needed services and needed medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care (authorization is required).

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 physician's services to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a manual wheelchair and accessories to be provided by the out-of-network provider.

You asked the Plan to pre-approve the manual wheelchair and accessories to be provided by the out-of-network provider. The Plan denied your request. The Plan says the service is available with a network provider.

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 items at issue in this appeal. We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a manual wheelchair and accessories to be provided by the out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS)
unit.

You asked the Plan to pre-approve a TENS unit. You say that this treatment is medically necessary for your
condition. The Plan denied your request. The Plan says you are not enrolled in a clinical study.

The Plan must follow Medicare rules. Medicare rules say that a TENS unit is covered for chronic low back
pain when there is enrollment in a clinical study.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of a TENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve
a transcutaneous electrical nerve stimulation (TENS) unit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rheumatology services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve OON services. You say that you need to be properly tested. The Plan denied your request. The Plan says medically necessary care is available in-network.

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 OON services. Therefore, we decided that the Plan does not have to pre-approve rheumatology services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries.

You asked the Plan to pre-approve a duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925). You say that the enrollee needs these procedures. The Plan denied your request. The Plan says no ankle-brachial indices have been documented in this case.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. An ABI has not been done yet. Based on this information, we decided that Medicare rules for coverage of a duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study (93925) have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries (93925).