Persius/hicric huggingface dataset:
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 admission to an IRF is medically necessary. The Plan denied your request. The Plan says criteria for an IRF are not met, and the enrollee can safely receive the necessary care in other settings.

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 that the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.

The enrollee does require physical and occupational therapy, but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that this enrollee 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve three further physical therapy visits, for a total of six.

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 not medically necessary.

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 these services. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional therapy is not generally accepted as specific and effective therapy for your condition beyond the three approved visits. You have had prior therapy and the records do not show that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under supervision of a therapist. You have been instructed in a home exercise program. The services are not part of a maintenance program and not needed to design and/or deliver a program to maintain your current condition or prevent 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve three further physical therapy visits, for a total of six.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the echocardiography services (93306) provided on March 18, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the echocardiography services. You say that you would like this claim reprocessed for medical necessity for your condition. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 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 the echocardiography services (93306) provided on March 18, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on January 8, 2021.

You asked the Plan to pay for lab test. You say that you are appealing with supporting records. The Plan denied
your request. The Plan says the denial of payment for this test is correct, because this test is not a covered
benefit for the diagnoses listed and was performed for screening purposes.

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 test at issue in this appeal, lab test, was requested for screening purposes. Medicare does not cover this test
for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided
on January 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (97530) provided on October 7, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.

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 97530 is "Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes."

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 use of code 97530 is not supported by the records provided. Our coding reviewer found that an Occupational Therapist performed these services in the home setting. HCPCS code G0152 is a more appropriate code to report for this service. 

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 the services (97530) provided on October 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (20206) provided on December 10, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed service is not supported.

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 20206 is "Biopsy, muscle, percutaneous needle." 

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 use of code 20206 is not supported by the records provided. Our coding reviewer found that the procedure report documents "12-gauge Suros ATEC needle was advanced and 6 samples were taken. A marker was placed."

CPT 20206 is an inappropriate code to report for this procedure. There is a more appropriate code to report for a needle biopsy, therefore, CPT 20206 cannot be confirmed. 

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 the services (20206) provided on December 10, 2020.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says there is no evidence that the enroll needs an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.

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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hip pain after recent hip surgery. The enrollee's medical conditions are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does 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 this enrollee 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda.
You asked the Plan to pre-approve Keytruda. You say that the medication is necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
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 Keytruda. Our reviewer says that the medication is medically necessary. Our physician reviewer found Pembrolizumab (Keytruda) is FDA approved as single-agent treatment of recurrent or metastatic head and neck squamous cell carcinoma (HNSCC) in patients with disease progression on or after platinum-containing chemotherapy. This enrollee has recurrent disease after chemotherapy and radiation and meets coverage criteria. The service is reasonable and 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 Keytruda have been met. Therefore, we decided that the Plan has to pre-approve Keytruda.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
You asked the Plan to pre-approve a HFCWOD. You say that the requested HFCWOD is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested HFCWOD.
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases. 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 HFCWOD. Our reviewer says that the enrollee does not meet criteria for the requested HFCWOD. Our physician reviewer found the record indicates that the enrollee has had a stroke and has chronic respiratory failure due to tracheostomy. The record does not indicate that the enrollee has cystic fibrosis, bronchiestasis, or an enumerated neuromuscular disease. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a HFCWOD have not been met. Therefore, we decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance response and treatment, no transport (A0998) provided on March 18, 2021.

You asked the Plan to pay for ambulance response and treatment, no transport. You say that you are disputing the charges because you were told to get in the ambulance to be checked. The Plan denied your request. The Plan says that the ambulance benefit is a transportation benefit and without a transport, there is no payable service. The Plan says the service at issue is not covered.

Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 

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 ambulance response and treatment, no transport. Our reviewer says that your presenting symptoms meet prudent layperson criteria for emergency care. Our physician reviewer found that you found fire alarms going off in your residence for one hour. Emergency Medical Services observed an oxygen level of 86% with no respiratory distress. You received oxygen supplementation. Oxygen levels went up to 95% and remained normal even after removal of oxygen. You were not transported to the hospital. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ambulance response and treatment, no transport have been met. Specifically, your presenting symptoms meet prudent layperson criteria for emergency care.

We do not see (within the record) that the Plan made any attempts to determine if there was a qualifying community-wide EMS protocol in this case. Therefore, we decided that the Plan has to pay for ambulance response and treatment, no transport (A0998) provided on March 18, 2021.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous lumbar discectomy.

You asked the Plan to pre-approve percutaneous lumbar discectomy. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve percutaneous lumbar discectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found percutaneous lumbar discectomy remains experimental. More research is needed to show safety and efficacy of the procedure.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous lumbar discectomy have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous lumbar discectomy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve these services. You say that this treatment is considered safe and effective, as supported by its clinical benefits to patients. The Plan denied your request. The Plan says that it is not evident that the use of Vertiflex is an evidence based or safe mode for treating the enrollee's spinal stenosis.
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 requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed to show safety and efficacy of the device. 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 Vertiflex device for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on October 22, 2020.
You asked the Plan to pay for lab tests. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, because Medicare denies coverage for all cardiovascular risk assessment testing/panels - except the basic lipid panel - for symptomatic patients with suspected or documented cardiovascular disease.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. This testing was ordered by an in-network provider. The file does not show that the plan provided notice that lab tests would not be covered. Under Medicare rules, this means lab tests is considered approved by the plan. Therefore, we decided that the Plan has to pay for laboratory testing provided on October 22, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis for the enrollee.

You asked the Plan to pre-approve Lucentis. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not have any stated contraindications to the preferred products.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Lucentis. Our reviewer says that Lucentis is not medically reasonable and necessary for the enrollee in this case. The patient has not tried and failed Avastin, Mvasi or Zirabev. The plan's required drug(s) would not likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Lucentis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyperbaric Oxygen Therapy.

You asked the Plan to pre-approve Hyperbaric Oxygen Therapy. You say that you need to undergo a wound
cleaning due to your Type 1 Diabetes Mellitus with foot ulcer. The Plan denied your request. The Plan says the
member does not meet Medicare criteria for coverage of Hyperbaric Oxygen Therapy for diabetic wounds of
the lower extremity at this time as the member is responding to standard wound therapy and has a Wagner 2
wound.

The Plan follows Medicare rules. Medicare rules say that Hyperbaric Oxygen Therapy will be limited to that
which is administered in a chamber (including the one-man unit) and is limited to specific conditions.

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 Hyperbaric Oxygen Therapy.

Our reviewer says that Hyperbaric Oxygen Therapy does not meet Medicare criteria. Our physician reviewer
found that per the Medicare National Coverage Determination (NDC), in relevant part, that coverage for HBO
is for diabetic wounds of the lower extremities in patients who meet the following three criteria:
Patient has type I or type II diabetes and has a lower extremity wound that is due to diabetes;
Patient has a wound classified as Wagner grade III or higher; and
Patient has failed an adequate course of standard wound therapy.

In this case, the record indicates that you have diabetes with a foot ulcer in the presence of diabetic neuropathy.
The record indicates that the ulcer is up to 25% epithelialized and has the remainder as pink granulation
tissue. Photographs were supplied for review. The record does not support the presence of a Wagner 3 or
higher ulcer. The elements of the coverage criteria are not satisfied. The requested service cannot be
recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Hyperbaric Oxygen Therapy have not been met. Therefore, we decided that the
Plan does not have to pre-approve Hyperbaric Oxygen Therapy.