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

We decided that the Plan does not have to preapprove a Group 3 Power Mobility Device.
You asked the Plan to preapprove a special power wheelchair. You say that you require the special Group 3
power wheelchair. The Plan denied your request. The Plan says you do not meet the Medicare coverage criteria
requirements.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. Therefore, we decided that the Plan does not have to preapprove a Group 3
Power Mobility Device.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on June 19, 2020.

You asked the Plan to pay for these services. You say that this claim should be paid by the Plan. The Plan denied your request. The Plan says while code 86328 was paid, the remained of the claim was denied due to issues with the Place of Service (POS) code reported. The Plan states an independent lab bust report the POS code in which the specimen was taken. Medicare billing criteria were not met.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case the claim cannot be paid as billed for the codes remaining due to an error with the POS code reported. Medicare billing criteria are not met.

Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on June 19, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ergonomic knife and cutting board.

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 items are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we
decided that the Plan does not have to pre-approve an ergonomic knife and cutting board.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission and services. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is not stable and needs assistance 
walking from room to room. You are the enrollee's primary care giver and are currently unable to provide care. 
The Plan denied your request. The Plan says the enrollee does not meet the criteria for admission to an SNF. 

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 the enrollee does not require skilled 
nursing services that must be provided with the specialized skill, knowledge and judgement of a skilled 
professional nurse. The documentation does not reveal evidence of complex daily wound care, new enteral 
feedings, or other skilled nursing needs. The enrollee's functional level does not require skilled therapy 
services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively 
provide medically necessary and reasonable treatment in a SNF. The patient does not require skilled nursing or 
skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical 
matter, this patient does not require the necessary services on an inpatient basis, in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of a mental health inpatient psychiatric admission beginning July 20, 2021.
You asked the Plan to pre-approve continuation of the mental health inpatient psychiatric admission. You say that continuation of these services is medically necessary. The Plan denied your request. The Plan says the enrollee no longer meets the criteria for this level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the mental health inpatient psychiatric services. Our reviewer says that continuation of the mental health inpatient psychiatric admission is not medically necessary. Our physician reviewer found based upon review the records provided it was not expected you would improve in a reasonable period of time beyond the dates in question as you were not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. You were compliant with treatment and having no side effects to the medication. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as you did not have any suicidal or homicidal thoughts, hallucinations or aggressive behaviors. The health Plan's denial of continued inpatient psychiatric services appears appropriate. You did not require inpatient mental health treatment beyond the dates in question as noted above as you were not a danger to yourself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of July 20, 2021 forward and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and you were not showing any aggressive behaviors being cooperative and compliant. 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 mental health inpatient psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of a mental health inpatient psychiatric admission beginning July 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
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. 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 services are not medically necessary. Our physician reviewer found the enrollee has chronic lumbar pain and spinal stenosis. The Superion spacer may be implanted at one or two adjacent lumbar levels in patients in whom operative treatment is indicated at no more than two levels, from L1 to L5. The request is for implantation at levels L3-L4 and L4-L5. The services are therefore not covered. 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 a Vertiflex Superion spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 2, 2020.

You asked the Plan to pay for lab services provided to the enrollee. You say that this service should be paid by the Plan. The Plan denied your request. The Plan says the claim was not submitted with an appropriate POS code. The Plan states an Independent or Reference Laboratory must show the place where the sample was taken (if drawn in an Independent Lab or a Reference Lab, POS 81 is reported; if drawn in a hospital inpatient setting, the appropriate inpatient POS is reported). All entities billing for laboratory services should append identifying modifiers when appropriate, in accordance with correct coding.

If an independent laboratory bills for a test on a sample drawn on an inpatient or outpatient of a hospital, it reports the code for the inpatient (POS code 21) or outpatient hospital (POS code 22). The POS code reported is not supported by the records provided.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case this claim cannot be paid as billed due to an invalid POS code. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 2, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 9 home health physical therapy visits.
You asked the Plan to pre-approve 9 home health physical therapy visits. You say that the request is medically necessary. The Plan denied your request. The Plan says the home health physical therapy visits are not reasonable and necessary.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services. 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 9 home health physical therapy visits. Our reviewer says that the request is not medically reasonable and necessary. Our physician reviewer found based on the documentation provided, physical therapy visits are not necessary. Initially dependent for transfers, the enrollee is currently ambulating more than 100 feet. The enrollee does not have a documented need for ongoing skilled physical therapy. As such, the requested home health physical therapy services are not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 home health physical therapy visits.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve bariatric surgery (43775, 43281).
You asked the Plan to pre-approve bariatric surgery. You say that the procedure is medically necessary. The
Plan denied your request. The Plan says that coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that bariatric procedures are covered when 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 bariatric surgery. Our reviewer says
that the requested procedure is medically necessary. Our physician reviewer found the patient is an adult with a
BMI that is greater than 35 kg/m2, and the patient has several serious obesity related conditions such as sleep
apnea and hypertension. The patient has failed conservative efforts at weight loss including supervised weight
loss. The patient meets all criteria for bariatric surgery.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of bariatric surgery have been met. Therefore, we decided that the Plan has to preapprove
bariatric surgery (43775, 43281).
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81223, 81302, 81330, 81345, 81407, 81408,
81479) provided October 16, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the services were requested for screening purposes and are non-covered.
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, the lab services, was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab
services (81223, 81302, 81330, 81345, 81407, 81408, 81479) provided October 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a vaccination with Heplisav-B. You asked the Plan to pre-approve Heplisav-B. You say that your doctor and oncologist have recommended the requested vaccination since you are undergoing radiation treatments and are at increased risk of infections. The Plan denied your request. The Plan says rules for immunizations have not been met. Medicare rules say that Part B covers the hepatitis B vaccine and its administration when furnished to a beneficiary who is at high or intermediate risk of contracting hepatitis B. Identified high and intermediate-risk groups are listed in the Medicare rules section. The case record does not show that you belong to a high or intermediate risk group for contracting hepatitis B. Therefore, we decided that the Plan does not have to pre-approve a vaccination with Heplisav-B.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trelstar.
You asked the Plan to pre-approve Trelstar. You say that the medication is 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. 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 Trelstar.
Benefits for Trelstar are 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 the wheelchair ramp for your vehicle.

You asked the Plan to pre-approve the wheelchair ramp. You say that you require the ramp to go places. The
Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair ramps for
vehicles.

The wheelchair ramp you have requested is noncovered. Therefore, we decided that the Plan does not have to
pre-approve the wheelchair ramp for your vehicle.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the outpatient mental health services. You say that you have used this provider in the past and would like to continue using this provider. The Plan denied your request. The Plan says the provider is not in-network. The services are not emergent, and the type of provider requested is not eligible for Medicare payment. There are network providers available.
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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.
You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the Vertiflex procedure is still considered investigational/experimental.
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 Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the enrollee has chronic low back pain and spinal stenosis. The record indicates that imaging has demonstrated severe spinal stenosis at L3-L4, the level requested for treatment. The elements of the coverage criteria are not satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
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 provided on February 3, 2021.
You asked the Plan to pay for the supply allowance for therapeutic continuous glucose monitor (K0553). You say that the Plan should pay this claim. The Plan denied your request. The Plan says medical records document only oral medication no insulin.
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 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 the supply allowance for therapeutic continuous glucose monitor (K0553) have not been met. Therefore, we decided that the Plan does not have to pay for the supply allowance for therapeutic continuous glucose monitor provided on February 3, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an 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 patient's nursing, medical and rehabilitation needs
does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
patient's current medical condition does not require intensive physician or nursing supervision in an IRF. The
patient may benefit from additional physical and occupational therapy but the documentation does not reveal
that this therapy must be provided only on an intensive level 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 an acute inpatient rehabilitation facility (IRF) admission and services.