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

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the requested SNF care is a necessity for you as you do not have needed care at home. The Plan denied your request. The Plan says rules for SNF care have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that you do not qualify for SNF care. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for targeted genomic sequence analysis (0037U) provided on August 22, 2019 by an out of network (OON) provider.

You asked the Plan to pay for the diagnostic services. You say that the enrollee meets the requirements of the NCD and has been determined by CMS to be reasonable and necessary for the management of the enrollee's advanced cancer. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 targeted genomic sequence analysis (0037U) provided on August 22, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after June 16, 2021.

You asked the Plan to pre-approve SNF care. You say that you are not physically able to return home and be independent. The Plan denied your request. The Plan says the denial of authorization for continued SNF care after June 16, 2021 is correct.

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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a Skilled Nursing Facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued Skilled Nursing Facility (SNF) care after June 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 additional chiropractic therapy visits
You asked the Plan to pre-approve the chiropractic visits. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the additional visits do not meet the LCD medical necessity criteria.
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 chiropractic visits. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has lumbar back with pain, segmental and somatic dysfunction. The enrollee is primarily complaining of spasm and some pain after doing yard work. The provided documentation does not indicate that any attempt has been made to transition to a home exercise program during the 14 already approved visits. The submitted documentation does not indicate the treatment plan or any change in the clinical scenario to justify the ongoing visits. The elements of the coverage criteria are not satisfied. 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 chiropractic visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 8 additional chiropractic therapy visits
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder orthosis provided by an out-of-network provider on October 5, 2020.

You asked the Plan to pay for the shoulder orthosis. You say that the physician ordered this product for home use to protect from further injury and reduce pain. You say that this was medically necessary, and the charges should be allowed. The Plan denied your request. The Plan says prior authorization was required but not obtained.

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 the shoulder orthosis provided by an out-of-network provider on October 5, 2020.
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 inpatient psychiatric care. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for inpatient psychiatric care have not been met.

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 inpatient psychiatric care. Our reviewer says that the requested services are not medically necessary. Our physician reviewer found that the enrollee does not meet the criteria for continued treatment in an acute inpatient mental health treatment beyond the date of June 15, 2021, forward and could have been treated in a lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression, being cooperative and compliant while not showing any acute threats to safety

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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric care.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. You say that inpatient management is the next course of action in the enrollee's treatment after multiple drug trials. The Plan denied your request. The Plan says that rules for inpatient care have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the proposed infusions in this case are generally done over a series of days. The enrollee's prior admissions had also spanned more than 2 midnights. In this setting it can be said that the proposed course of treatment is expected to last beyond two midnights and therefore the requirements for inpatient care are met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Stryker Spine Jack Vertebral Augmentation System.
You asked the Plan to pre-approve the Stryker Spine Jack Vertebral Augmentation System. You say that you would like reconsideration because this procedure is medically necessary. The Plan denied your request. The Plan says the clinical value of and effectiveness of the Stryker Spine Jack Vertebral Augmentation System in the setting of an acute vertebral compression fracture with adjacent compression fractures have not been demonstrated in the peer-reviewed literature to be safe and effective.
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 Stryker Spine Jack Vertebral Augmentation System. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
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 Stryker Spine Jack Vertebral Augmentation System have not been met. Therefore, we decided that the Plan does not have to pre-approve the Stryker Spine Jack Vertebral Augmentation System.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation of speech fluency services provided on May 22, 2020.

You asked the Plan to pay for the evaluation of speech fluency services. You say that you would like the plan to reconsider their denial. 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 92521 is evaluation of speech fluency (eg, stuttering, cluttering).

We find that CPT code 92521 is not supported in the medical record. Specifically, the documentation shows that the speech-language pathologist visit was provided in a home health setting. There is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the evaluation of speech fluency services have not been met. Therefore, we decided that the Plan does not have to pay for the evaluation of speech fluency services provided on May 22, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit (99347) provided on October 25, 2019.
You asked the Plan to pay for a home visit. You say that this was medically necessary. The Plan denied your
request. The Plan says this was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code. Home services codes 99341-99350 are paid
when they are billed to report evaluation and management services provided in a private residence. A home
visit cannot be billed by a physician unless the physician was actually present in the beneficiary's home.
We find that CPT code 99347 is not supported in the medical record. Specifically, the record does not show
that the billing physician was present in the enrollee's home. Based on this information, we decided that
Medicare rules for coverage of a home visit have not been met. Therefore, we decided that the Plan does not
have to pay for a home visit (99347) provided on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) including sales tax (S9999) purchased on December 8, 2020.
You asked the Plan to pay for a portable oxygen concentrator and sales tax. You say that the enrollee needs the portable oxygen machine to leave the house for appointments. The Plan denied your request. The Plan says rules for payment for oxygen equipment have not been met.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a portable oxygen concentrator and sales tax have not been met. Therefore, we decided that the Plan does not have to pay for a portable oxygen concentrator (E1392) including sales tax (S9999) purchased on December 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Optune device for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that the chart notes indicate that the tumor is grade 2 which does not
meet the criteria.
The Plan follows Medicare rules. Medicare rules say that TTFT is covered if the LCD criteria has been met.
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
these services are not medically reasonable and necessary for the enrollee in this case. The enrollee has a grade
2 astrocytoma of the frontal lobe. Our physician reviewer found that the enrollee's condition does not meet
Medicare criteria for these services.
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 the Optune device 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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that you 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve breast Magnetic Resonance Imaging (MRI).
You asked the Plan to pre-approve breast MRI. You say that the enrollee is at intermediate risk and this MRI is
recommended. The Plan denied your request. The Plan says the enrollee does not meet the Medicare coverage
criteria for this breast MRI.
The Plan follows Medicare rules. Medicare rules state that breast MRI studies are only to be used under
specific circumstances.
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 breast MRI. Our reviewer says that the
enrollee does not meet the Medicare criteria for the requested breast MRI. Our physician reviewer found the
enrollee has a history of lobular carcinoma in situ for which she was treated in 2010. Follow-up ultrasound and
mammograms show dense breast tissue, but no abnormal or inconclusive findings.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of breast MRI have not been met. Therefore, we decided that the Plan does not
have to pre-approve breast Magnetic Resonance Imaging (MRI).
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 you feel that you require SNF care for
your condition. The Plan denied your request. The Plan says the Medicare criteria for SNF admission have not
been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed 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 beneficiary is a 74-year-old
female with a history of kidney transplant, atrial fibrillation, diabetes, pneumonia, dysphagia, weakness, and
urinary tract infection. From a nursing perspective, the beneficiary received oral medications and had stable
vital signs. Regarding rehabilitation services, the beneficiary received physical and occupational therapy in the
acute hospital. The beneficiary was at a maximal assist to dependent level with functional mobility and she had
been non-ambulatory. The beneficiary required varying assist with daily living activities.

There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs.
This beneficiary 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onpattro.

You asked the Plan to pre-approve Onpattro. You say that this is medically necessary. The Plan denied your request. The Plan says this is part of a clinical trial.

The Plan must follow Medicare rules. Medicare rules say that original Medicare covers the routine costs of qualifying clinical trials for all Medicare enrollees, including those enrolled in Medicare Advantage plans, as well as reasonable and necessary items and services used to diagnose and treat complications arising from participating in qualifying clinical trials. 

We looked at the file and Medicare rules. The record shows that the requested medication is being provided as part of a clinical trial. The Plan is not responsible for coverage of clinical trial costs. Based on this information, we decided that Medicare rules for coverage of Onpattro have not been met. Therefore, we decided that the Plan does not have to pre-approve Onpattro.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 27, 2021.
You asked the Plan to waive the copayment for the office visit. You say that the provider indicated there would be no charge for the visit since no service was performed. The Plan denied your request. The Plan says the copayment 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 a $50 copayment for office visits to in-network specialists at an independent office.
You have been asked to pay a $50 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on January 27, 2021.