Persius/hicric huggingface dataset:
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 SNF care. You say that SNF care is medically necessary for the enrollee's
condition. 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 based on the documentation provided, the enrollee does not qualify for SNF coverage. The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. The enrollee is ambulating more than 100 feet and tending to activities of daily living with minimal supervision. 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, 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 admission to a skilled nursing facility (SNF).
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 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 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 there are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services is not sufficiently supported and will be considered not medically necessary. Transfer to a lower level of care may be considered soon. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Oxycontin 30 mg tablet.

You asked the Plan to pre-approve Oxycontin. You say that this request is medically necessary for the
enrollee's condition. The Plan denied your request. The Plan says drug coverage is limited only to those drugs
covered under your medical benefit.

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 Oxycontin 30 mg tablet.

Benefits for Oxycontin 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a retainer inlay represented by common procedural terminology (CPT) code D6600.
You asked the Plan to pre-approve CPT code D6600. You say that you blacked out and fractured your jaw, suffered a concussion, split open your chin, and had great damage to many teeth. You say that, as a result of this, you have been unable to eat much and have lost a considerable amount of weight. You say that two of the fractured teeth became infected and had to be removed. You say that the documentation provided supports the need for the service in dispute and that your health is in jeopardy. The Plan denied your request. The Plan says the service which remains in dispute is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a retainer inlay represented by common procedural terminology (CPT) code D6600.
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 you disagree with the denial. 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 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 medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on May 23, 2021 with COVID-19. The therapy notes state she needs modified assist of two for rolling, scooting, and sitting up and maximum encouragement to participate. The records show that she does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of rehabilitative services and regular physician evaluation. 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 t
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 acute inpatient rehabilitation is necessary for you to
return to your prior level of function and independence. The Plan denied your request. The Plan says based on
your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily
therapy. The medical records do not support the need for an intensive rehabilitation therapy program consisting
of at least 3 hours of therapy per day at least 5 days per week. Criteria for admission to an IRF have not been
met; your skilled therapy and nursing needs can be provided at a lower level of care such as a skilled nursing
facility, at home with home health care, or in a long-term setting.
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 require physical
and occupational therapy but there is no documented need for an intensive rehabilitation program. 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. Medically necessary services can be provided in a different level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem.
You asked the Plan to pre-approve Zolpidem. The Plan denied your request. The Plan says Zolpidem to be administered at home is not covered under the Part B benefit.
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 Zolpidem.
Benefits for Zolpidem 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the GeneSight testing rendered on December 4, 2020.
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 the testing was not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that pharmacogenetics testing is covered when specific criteria are 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 pay for these services. Our reviewer says that the testing was not medically necessary. Our physician reviewer found the enrollee has a diagnosis of moderate major depressive disorder. The limited documentation does not clearly show the use of or intent to prescribe a drug that has known drug-gene interactions that requires a PGx test to be ordered to define the safe use of that drug in this enrollee. The documentation is insufficient to demonstrate that it was reasonable and medically necessary for this enrollee to have GeneSight testing. 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 pay for the GeneSight testing rendered on December 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical placement of endosteal implant (D6010).
You asked the Plan to pre-approve the surgical placement of endosteal implant. You say that you are not able to eat and need these services performed. The Plan denied your request. The Plan says the requested procedure is not among those covered under your supplemental dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of endosteal implant (D6010).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS) unit (L8679, 64555).

You asked the Plan to pre-approve the PENS unit. You say that the enrollee has tried and failed conservative care and medication therapies. Based on history and diagnosis, the provider is recommending the neurostimulator to decrease pain. The Plan denied your request. The Plan says there is not enough studies to show nerve stimulator behind the ear will help in your care. CPT codes L8679 and 64555 are for implantable stimulators and are not the correct codes for PENS or PNT device. The correct code for electro acupuncture devices is CPT 64999.

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. Based on this information, we decided that Medicare rules for coverage of the PENS unit have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous electrical nerve stimulation (PENS) unit (L8679, 64555).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cold circulating pad (E0218).

You asked the Plan to pre-approve the cold circulating pad. You say that you would like reconsideration because this equipment helps to prevent blood clots. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that a fluid circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cold circulating pad have not been met. Specifically, per Medicare guidance, the requested equipment will be denied as not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve the cold circulating pad (E0218).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Minuteman procedure.

You asked the Plan to pre-approve the Minuteman procedure. You say that this request is medically necessary
for the enrollee. The Plan denied your request. The Plan says the requested procedure is considered not
medically necessary and reasonable as it is experimental/investigational.

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 Minuteman procedure. 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 a 69-year-old male who is being treated for
spondylolisthesis lumbar region. He presents with chronic low back pain. He reports that sitting at rest, his pain
is very minimal. He stands for extended periods of time or transitions from sitting to standing. He will
experience a great deal of axial low back pain. He reports bilateral leg weakness since his last office visit.
Current evidence based medical guideline and peer reviewed literature do not fully support the interspinous
fusion device procedure over the 'gold standard' of lumbar fusion. There is a lack of large volume, long-term
peer-reviewed outcome studies to support the use of this device for this enrollee's medical condition as
discussed above. In addition, fusion indications within guidelines/literature for (existing or potential
intraoperative) instability have not been documented and/or met in this case. There are multiple spinal alternate
pain generators plausibly significantly contributing to the clinical condition that have not been fully
documented as having been excluded and/or ruled out. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines.
Therefore, the request for Minuteman Procedure at L4-S1 is not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the Minuteman procedure have not been met. Therefore, we decided that the
Plan does not have to pre-approve the Minuteman procedure.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.

You asked the Plan to provide a therapeutic continuous glucose monitor system. You say that your fingertips are sore from finger stick testing. The Plan denied your request. The Plan says you are not insulin treated therefore criteria is not met for a CGM.

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 does not indicate that you use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor system have not been met. Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services (CPT 99214) provided to the enrollee on January 11, 2021.

You asked the Plan to pay for the services. You say that the Arizona Health Care Cost Containment System (AHCCCS) have established two telephonic code sets for provider use in order to deliver services during the COVID-19 public health emergency. The Plan denied your request. The Plan says this was billed with an inappropriate place of service.

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 99214 is "Office or outpatient visit for the evaluation and management of a new patient." 

We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found the provider billed CPT 99214 with place of service 12 Home. Per Medicare "During the COVID-19 crisis, Medicare will pay the non-facility amount for telehealth services when they are billed with the place of service (POS) the physician would have used if the service had been provided in person (e.g., POS 11 - Office). Therefore, 12 is the incorrect place of service for services provided. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for office visit services (CPT 99214) provided to the enrollee on January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for urology services provided on January 5, 2021.
You asked the Plan to pay for urology services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 pay for urology services. Our reviewer says that these services do not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the documentation is insufficient to demonstrate whether the enrollee could have foreseen requiring these services prior to leaving the Plan's service area. These services were medically necessary. It would have been medically reasonable to delay the services until the enrollee returned to the Plan's service area, disenrolled from the Plan, or up to 6 months. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of urology services have not been met. Therefore, we decided that the Plan does not have to pay for urology services provided on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office services. You say that you see this provider for breast cancer and you feel your life is in jeopardy due to breast cancer if you cannot keep seeing this specialist. The Plan denied your request. The Plan says you do not meet the standards for out-of- network care and the request cannot be approved. The Plan states they approved your office visit with a doctor who treats blood diseases and cancer to be provided by an in-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/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 the office services to be provided by an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on October 21, 2020.

You asked the Plan to waive the copayment for the CT scan. You say that you were never told you would have a copayment and cannot afford it. 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 $0 copayment for mammography and ultrasounds and a $225 copayment for all other diagnostic and nuclear medicine radiological services.

You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the CT scan provided on October 21, 2020.