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

We decided that the Plan does not have to pre-approve Dexcom g6.
You asked the Plan to pre-approve Dexcom g6. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested item.
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 documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of Dexcom g6 have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom g6.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness (E2313), and electronic connection (E2311) for a Group 3 power wheelchair.
You asked the Plan to pre-approve an expandable controller, expandable harness, and electronic connection. You say that the requested items are medically necessary for the enrollee. The Plan denied your request. The Plan says the requested items are not medically reasonable and 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 an expandable controller, expandable harness, and electronic connection. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.). The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength and function in the upper extremities with the ability to be supervised for eating and minimal assist grooming supports that the enrollee can control any power options through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller, expandable harness, and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable harness (E2313), and electronic connection (E2311) for a Group 3 power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orgovyx.
You asked the Plan to pre-approve Orgovyx. You say that the enrollee poorly tolerated Leuprolide. The Plan denied your request. The Plan says this medication does not fall under 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 Orgovyx.
Benefits for Orgovyx 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve True Metrix blood glucose test strips.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from the preferred provider.
The Plan must follow Medicare rules. Medicare rules say that Plans may limit enrollees to preferred providers for durable medical equipment and supplies. We looked at the file and Medicare rules. The requested services are True Metrix test strips. This is not a preferred provider with the Plan. The Plan offers test strips from LifeScan branded products. Therefore, we decided that the Plan does not have to pre-approve True Metrix blood glucose test strips.
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 enrollee will require 3-4 weeks of vent weaning. The Plan denied your request. The Plan says the enrollee is not stable enough to leave the hospital.
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 physician reviewer found that the enrollee was admitted to the acute hospital for Covid-19. His hospital course was complicated by an acute pulmonary embolus, superimposed bacterial pneumonia, a large sacral decubitus ulcer, metabolic encephalopathy, and severe caloric malnutrition. He is receiving appropriate care at the present acute care hospital. He does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Therefore, the requested LTACH services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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 additional physical therapy.
You asked the Plan to pre-approve additional services. The Plan denied your request. The Plan says the enrollee does not require the skills of a therapist.
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 additional services. Our physician reviewer found that the enrollee attended 9 PT sessions with good compliance to a home exercise program. She had minimal objective/subjective improvement. She has low back pain which fluctuates. She can flex the lumbar spine without limitations. She has minimal limitations in lumbar range of motion. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, or that the services can be performed only by a therapist. The requested services are not part of a maintenance program or needed to deliver a program to maintain her 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 additional services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance service (A0429) and ground
mileage (A0425) provided October 31, 2020.
You asked the Plan to pay for the ambulance services. You say that you were informed this claim denied due to
invalid procedure code for services provided. Please see attached report showing the enrollee was transported
via ambulance and was provided basic life support (BLS A0429). The Plan denied your request. The Plan says
on this date of service the enrollee was inpatient hospital status.
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, we find that CPT code A0429-SH and A0425-SH is not supported in the medical record.
Specifically, the claim was billed with the incorrect location code. The claim has to rebilled with the correct
location code as the enrollee was in a skilled nursing facility. Based on this information, we decided that
Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan
does not have to pay for the BLS emergency ambulance service (A0429) and ground mileage (A0425)
provided October 31, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone marrow aspiration for bone grafting (20939).
You asked the Plan to pre-approve a bone marrow aspiration for bone grafting. You say that surgery is the only
option to fix the enrollee's medical issue. The Plan denied your request. The Plan says the requested service is
not medically supported or accepted.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve a bone marrow aspiration for bone
grafting. Our reviewer says that the requested items/services are not considered medically reasonable and
necessary in this case. Our physician reviewer found that the enrollee is being treated for spinal stenosis,
lumbar region, with neurogenic claudication; and radiculopathy, lumbar region. The enrollee presented with
pain that is equally in the leg and the back. However, there is no specific indication provided to support the
request for bone marrow aspirate for the approved surgery. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction
with the lumbar surgery to be performed. There is a lack of large volume, long-term peer-reviewed outcome
studies to support the use of bone marrow aspirate for the enrollee's medical condition.
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 bone marrow aspiration for bone grafting have not been met. Therefore, we
decided that the Plan does not have to pre-approve a bone marrow aspiration for bone grafting (20939).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee can do more than what they offer in a sub-acute rehab. The Plan denied your request. The Plan says there is no need for physician supervision, or an intensive multidisciplinary approach to daily therapy.
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 physician reviewer found that the enrollee was admitted to the acute hospital for surgical repair of a hip fracture after a fall. Her medical problems are stable. There are no complex nursing needs. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for LTACH care have not been met.
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 that there is no documentation provided necessitating admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the Plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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 the LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on August 6, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that orthoses are only covered under certain medical indications. We looked at the file, and Medicare rules. The records provided do not include any previous objective findings from a physical exam. The records do not indicate a previous medical relationship between the enrollee and the provider outside of the phone call the records were created from. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses provided on August 6, 2020.
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 enrollee has a medical need for the SNF level of care. 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 of this letter 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, based on the documentation provided, the enrollee does not have documented skilled nursing or skilled therapy needs. The enrollee appears to be functioning at or near baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point are custodial. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump coded A4222.

You asked the Plan to pay for the infusion supplies for external drug infusion pump. 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 payable.

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 A4222 is infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately).

We find that CPT code A4222 is not supported in the medical record. Specifically, this code was billed with an inappropriate place of service. Based on this information, we decided that Medicare rules for coverage of the infusion supplies for external drug infusion pump have not been met. Therefore, we decided that the Plan does not have to pay for the infusion supplies for external drug infusion pump coded A4222.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued physical therapy services.
You asked the Plan to pre-approve physical therapy services. You say that the enrollee needs to improve his balance, gait, and endurance. The Plan denied your request. The Plan says the enrollee is unable to return to a higher level of functioning.
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 physical therapy services. Our physician reviewer found that the requested therapy is not generally accepted as effective therapy for the enrollee's condition beyond what was approved by the plan. He has had extensive prior therapy. The records do not demonstrate that the unique skills of a professional therapist are required to provide treatment, or that the services can only be performed by a therapist. The services are not part of a maintenance program. The services are not necessary to 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 physical therapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued physical therapy services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Zirabev (Q5118).
You asked the Plan to pre-approve Zirabev. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says the requested item is not medically reasonable and necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Zirabev. Our reviewer says that the requested treatment regimen is not medically reasonable and necessary. Our physician reviewer found that the requested use of Zirabev is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. Zirabev is not considered standard for first line treatment of occult primary adenocarcinoma. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Zirabev have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Zirabev (Q5118).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing services provided on July 8, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the place of service on the claim must reflect the location of the enrollee when the specimen was obtained.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim provided shows a place of service as 81. The medical records provided did not indicate the enrollee's sample was taken at an independent lab. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the lab testing services provided on July 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from acute rehab to optimize his level of functioning. The Plan denied your request. The Plan says the enrollee's care is not complex, and he does not need a team of providers.
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 physician reviewer found that the enrollee was admitted to the acute hospital for a fall and a urinary tract infection. His medical problems are stable. There are no complex nursing needs. He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy 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 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.