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

We decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (cgm) provided on February 22, 2021.

You asked the Plan to pay for the supply allowance for therapeutic CGM. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the items rendered are not a covered benefit.

The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone regarding the furnishing of a covered item except under specific circumstances.

We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the enrollee's treating physician. The record does not show that written permission was obtained to make contact by telephone regarding the furnishing of this item. The record does not show that contact was initiated regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the past 15 months. Based on this information, we decided that Medicare rules for coverage of the supply allowance for therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor (cgm) provided on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81406, 81407, 81408) provided on February 22, 2021.
You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this is supported in the records. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81406, 81407, 81408) provided on February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prosthetic legs.
You asked the Plan to pre-approve the requested items. The Plan denied your request. The Plan says coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.
The file shows that you received prosthetic devices on March 30, 2021. The prosthetics you have serve the same purpose as the requested items. Therefore, we decided that the Plan does not have to pre-approve prosthetic legs.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve the CardioMEMS device.
You asked the Plan to pre-approve the CardioMEMS device. You say that the service is medically necessary. The Plan denied your request. The Plan says that the service is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CardioMEMS device. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found given the severe symptoms of recurrent chronic heart failure (CHF) which appears very sensitive to volume loading conditions, complexity of the medical situation and the failure to prevent acute CHF hospitalization in this patient, use of the CardioMEMS device is reasonable and has clinical data, expert opinion, and approved FDA indications to back up its use in selected appropriate clinical situations like this one. It would therefore not be considered investigational. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of [Shorter description of ITEM or SERVICE at issue, e.g. "a power wheelchair"] have been met. Therefore, we decided that the Plan has to pre-approve the CardioMEMS device.
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 continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that the enrollee is an excellent candidate for this system. The Plan denied your request. The Plan says the criteria is not met.
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 and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, or 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 the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee.
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 stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary.

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 there are no identifiable skilled nursing
service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing
or therapy services on a daily basis. This enrollee does not require skilled nursing or therapy services on a daily
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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
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 stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 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 hypotension and weakness and was discharged to skilled nursing on August 27, 2021. Medical problems 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.
While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary 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. 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on March 29, 2021.
You asked the Plan to waive the copayment for arthrocentesis. You say that you expected to pay a $25 specialist copayment and are on a fixed income. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
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 $275 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The record shows that you received arthrocentesis at an outpatient hospital facility on March 29, 2021. Arthrocentesis is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $275 copayment. You have been asked to pay a $275 copayment for arthrocentesis. Arthrocentesis falls within the outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on March 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox injections.
You asked the Plan to pre-approve Botox. You say that the enrollee has tried and failed other medications. The Plan denied your request. The Plan says medications provided by the pharmacy are not covered under the medical benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox injections.
Benefits for Botox 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infectious agent antigen detection by immunoassay technique (CPT code 87426) provided to the enrollee on June 15, 2020, by a non-Medicare approved/certified freestanding emergency facility.
You asked the Plan to pay for the service. You say that the services were rendered in good faith and you would like payment made on the claim. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The facilities in question are actually not hospitals and have no affiliation with a hospital. The free-standing emergency room (ER) facilities in question bill with National Provider Identification (NPI) numbers that are registered as a Clinic/Center for Emergency Care. As a result, due to the fact that these facilities are not hospitals, and are not affiliated with a hospital, they are actually unable to obtain Medicare approval/certification. Therefore, we decided that the Plan does not have to pay for infectious agent antigen detection by immunoassay technique (CPT code 87426)
provided to the enrollee on June 15, 2020, by a non-Medicare approved/certified freestanding emergency facility
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on August 28, 2020.

You asked the Plan to pay for the non-covered ambulance mileage. You say that you had no other way to the nursing facility because you had a stroke and your right side was immobilized. You also say that you feel you should only be held responsible for the $300 copayment for the ambulance ride, and no extra mileage. The Plan denied your request. The Plan says this service is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered.

We looked at your request, the file and Medicare rules. Based on this information we decided Medicare coverage criteria have not been met. Specifically, the record indicates that there are 18 Skilled Nursing Facilities that could provide the appropriate care and are closer to the referring hospital. The documentation also supports that you requested this Skilled Nursing Facility because it is closer to your home and family. Medicare only covers the mileage to the nearest appropriate facility. Therefore, we decided that the Plan does not have to pay for the non-covered ambulance mileage (A0888) provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have reimbursement for the oxygen equipment (CPT code(s): E1392 and E1390) purchased on March 8, 2021.
You asked the Plan reimbursement for the DME. You say that you made this purchase out-of-pocket to be reimbursed as you needed this specific model as it is easier for you to carry for long distance trips to the doctors. The Plan denied your request. The Plan says their call logs show that the need for prior authorization for this item was discussed prior to the purchase. The Plan states oxygen equipment is also rented through a DME supplier and is not purchased as new in most cases.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The Medicare rules say that only rented oxygen equipment is eligible for coverage. Purchased oxygen equipment is statutorily non-covered. Therefore, we decided that the Plan does not have reimbursement for the oxygen equipment (CPT code(s): E1392 and E1390) purchased on March 8, 2021.
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 LTACH care is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care and does not require transfer to a LTACH.

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 indicating 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 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. 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 long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre CGM.
You asked the Plan to pre-approve the FreeStyle Libre. You say that you would like reconsideration because the requested CGM is medically necessary. The Plan denied your request. The Plan says the member does not require frequent adjustment of insulin.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the FreeStyle Libre. Our reviewer says that based on the medical records provided there is no documentation that that the enrollee has been using a blood glucose monitor (BGM) and performing testing four or more times a day.
Our physician reviewer found a form included in the records contains an obvious alteration in which the response to this question was changed from three times per day to four times per day for glucose testing but the medical office visit note clearly states the enrollee is testing just three times per day. 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 FreeStyle Libre have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre CGM.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 25, 2021.

You asked the Plan to pay for the CT scan. The Plan denied your request. The Plan says only one unit of this service is 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. 

We find that a additional unit of CPT code 70450 is not supported in the medical record. Specifically, the records show that only one unit of CPT code 70450 was provided on the date of service in question, which was previously processed and paid by the Plan. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on March 25, 2021.
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. The Plan denied your request. The Plan says you are unlikely to tolerate 3 hours of intensive therapy daily.
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 you were admitted to the acute care hospital for respiratory failure and the coronavirus. Your medical problems are stable. 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. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro device.
You asked the Plan to pre-approve the MyoPro device. You say that you would like reconsideration because the member fully meets criteria and this device should be covered under their Plan. The Plan denied your request. The Plan says there are no records present from occupational or physical therapists that have treated the member with arm bracing and documented reasons why this device is appropriate and recommended.
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 MyoPro device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the primary source medical records do not indicate that standard therapy and treatments are less effective than the requested device. Documentation of standard treatments is not present in the submitted records.
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 MyoPro device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro device