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

We decided that the Plan does not have to pay for the presumptive drug testing provided to the enrollee on March 29, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the claim form must reflect the location of the enrollee when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that the place where the sample was taken is reported as the Place of Service. We looked at the file and Medicare rules. The records provided does not show that sample was taken in an independent laboratory. Based on the information provided, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the presumptive drug testing provided to the enrollee on March 29, 2019.
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, with the enrollee's many comorbidities, his clinical condition meets full acute inpatient rehabilitation criteria. You say that the enrollee's ability to remain in the community setting will be affected, averting unplanned admissions. You say that the enrollee is willing and able to tolerate 2 hours of therapy at minimum 5 days per week. The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval of IRF 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 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 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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional physical and occupational therapies, but does not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
You asked the Plan to pre-approve the device and sleeves. You say that The Plan denied your request. The Plan says that your request is not medically necessary because your records show you have not had the four week trial of the basic pump.
The Plan follows Medicare rules. The rules state that Medicare covers pneumatic compression device (E0652) for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when the beneficiary has lymphedema of an extremity as defined above, the coverage criteria for an E0650 or E0651 are met and the beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. 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 device and sleeves. Our reviewer says that these items are not medically reasonable and necessary in this case. The documentation does not reveal the clinical findings of lymphedema on physician progress reports which include: Marked hyperkeratosis with hyperplasia and hyperpigmentation; papillomatosis cutis lymphostatica, deformity of elephantiasis, or skin breakdown with persisting lymphorrhea. The records do not reveal lymphedema of the chest, trunk or abdomen and failure of a four-week trial with measurements with an E0650 or E0651 PCD. Our physician reviewer found your condition does not meet Medicare criteria for these items. 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 device and sleeves have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (denosumab) treatment.
You asked the Plan to pre-approve the Prolia treatment. You say that the enrollee needs this treatment due to low bone density which caused the fracture. The Plan denied your request. The Plan says there has been no treatment of low bone density thus far. Oral bisphosphonates should be trialed prior to treatment with Prolia.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Prolia treatment. Our reviewer says that the requested treatment is not considered medically reasonable and necessary. Our physician reviewer found the enrollee is a 72 year old male who broke his wrist following a mechanical fall. Prolia was prescribed for the treatment of osteopenia. Review of compendia support the use of oral bisphosphonate for treatment. The records do not include adequacy of vitamin D levels, treatment or contraindications to oral agents. Without the support of the documentation, medical necessity cannot be determined. 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 Prolia treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (denosumab) treatment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection (J2778 and 67028).
You asked the Plan to pre-approve the Ranibizumab. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is no documentation of a trial and failure of, contraindication to or intolerance of intravitreal bevacizumab (Avastin) and intravitreal aflibercept (Eylea).
The Plan must follow Medicare rules. Medicare rules say that to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Ranibizumab have not been met. The documentation does not include medical records to confirm that Medicare coverage criteria have been met. Therefore, we decided that the Plan does not have to pre-approve a Ranibizumab injection (J2778 and 67028).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out of network provider.
You asked the Plan to pre-approve an office visit. You say that you are requesting one consultation with this doctor regarding the procedure, bursitis, options for pain relief and revision of the procedure. Your surgeon had to perform unexpected and unplanned procedures during your surgery. Your surgeon states that had he known the extent of the wear he would have recommended that the surgery be done by this provider. The Plan denied your request. The Plan says this provider is not a network provider. The Plan has multiple surgeons who have done total joint fellowships. There are also multiple providers who have experience with complex cases and revisions. They would also be able to provide an opinion as to options such as surgical vs non-surgical options. 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 pre-approved care. 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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve an office visit (99214) to be provided by an out of network provider.
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 the services are medically necessary. The Plan denied your request. The Plan says the services are not medically 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 services are not medically necessary. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a hemorrhagic stroke. The enrollee was intubated/ventilated upon presentation. The enrollee has since been extubated, but is being maintained on average volume assured pressure support ventilation (AVAPS). 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 for ongoing acute care and goals of care discussions. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 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 you are appealing with medical records.
The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct.
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 does not require services at the LTACH that are not available at the
current acute care hospital where she is currently receiving care. The Plan has approved ongoing care in the
current acute care setting. Therefore, the requested LTACH services are not medically necessary, reasonable,
and appropriate for the diagnosis and condition of the enrollee at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: 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 the care can be received in another setting.
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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
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 reviewer says that the
services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on
January 5, 2020 with abdominal pain and loose stools. She is currently stable and needs total assistance with
care as of January 24, 2020. She has no complex medical, nursing, or rehabilitation needs that require an acute
hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear that she would be
able to participate in and fully benefit from an intensive therapy program in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 82533, 82550, 82607, 82627, 82728 and 82746 provided on May 14, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 82533, 82550, 82607, 82627, 82728 and 82746 are not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed and dated by the ordering physician). Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 82533, 82550, 82607, 82627, 82728 and 82746 provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implantable loop recorder.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has paroxysmal atrial
fibrillation. There is no documentation that the enrollee is not able to effectively manage 24-to-48 hour Holter
monitoring or auto-triggered cardiac event monitoring or that they have been tried and were found to be not
effective. There is only mention of skin irritation with Zio Patch, different from the above off line devices.
Current expert consensus guidelines endorsed by several national organizations also consider Holter
monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of
care for evaluation of dysrhythmias. The requested services are not reasonable or medically necessary at this
time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve an implantable loop recorder
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on August 29, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to the enrollee on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on August 16, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a
physician.
We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug testing rendered on August 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that a CGM is safer and more comfortable for you. The
Plan denied your request. The Plan says that you do not meet criteria for a CGM
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above
criteria have been met.
We looked at the file and Medicare rules. The file indicates you are not treated by insulin injections three or
more times a day or testing your blood glucose four or more times a day. Based on this information, we
decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan
does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 2, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says tests with no relation to a medical diagnosis of disease for the health of the enrollee are not a benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The testing at issue in this appeal was requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on August 2, 2019.