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

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of facet joint nerves (64635, 64636).
You asked the Plan to pre-approve radiofrequency ablation of facet joint nerves. You say that this is supported by the records. The Plan denied your request. The Plan says the records do not contain sufficient information about the enrollee's pain relief.
The Plan must follow Medicare rules. Medicare rules say that an initial thermal radiofrequency ablation of cervical, thoracic, or lumbar paravertebral facet joint (medial branch) nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic medial branch blocks (MBBs), with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). We looked at the file and Medicare rules. The submitted medical records do not include documentation showing that the enrollee has 80% sustained pain relief following each diagnostic MBB.
Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of facet joint nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of facet joint nerves (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 criteria are 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 use insulin. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FoundationOne genetic testing.
You asked the Plan to pre-approve genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because there is no defined benefit at this time for treatment based on this testing in the enrollee's condition.
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 genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee now has metastatic clear cell renal carcinoma originally treated with nephrectomy and multiple chemotherapy agents. The Medicare-approved compendia do not indicate that genetic testing is necessary to guide therapy in this clinical situation. The records do not demonstrate that the requested testing would be used to alter the enrollee's therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approve FoundationOne genetic testing.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mycophenolat tablets.
You asked the Plan to pre-approve Mycophenolat tablets. You say that the enrollee is stable on this medication. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.
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 Mycophenolat tablets.
Benefits for Mycophenolat tablets 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation SNF services provided from January 30, 2021, through February 28, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says based upon Medicare coverage guidelines; medical necessity cannot be established for continued stay at the skilled nursing facility.
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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that at the time of admission, the enrollee required skilled rehabilitation services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of January 30, 2021 the enrollee did not require any skilled nursing or rehabilitation services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or activities of daily living. The enrollee did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of January 30, 2021. The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube. The enrollee received skilled care and improved, however his function had plateaued by January 30, 2021 and he did not require any further inpatient skilled rehab services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of January 30, 2021 the enrollee required custodial services. The denial for further inpatient skilled care is upheld. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from January 30, 2021, through February 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 7, 2020 to July 15, 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 submitted records do not support the billing of DRG 292 and I11.0.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 292 and diagnosis code I11.0 (hypertensive heart disease with heart failure). 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 submitted records do not support the billing of DRG 292 and I11.0. Our physician reviewer found the enrollee was admitted to the hospital and treated following an unwitnessed fall. Creatine kinase was elevated and he was given intravenous fluids. Chest x-ray showed mild pulmonary edema and fluids were stopped. He was then given Lasix. ECHO showed grade 3 diastolic dysfunction. Hypertensive heart disease with heart failure was diagnosed (primary diagnosis). Based on the documentation provided the fall and resulting muscle injury was the primary condition requiring admission and the heart failure was a secondary diagnosis only. Therefore, the DRG 292 is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from July 7, 2020 to July 15, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from October 16, 2020, through November 16, 2020.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says the SNF services are 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 pay for the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on review of the available records, the enrollee did not meet the CMS coverage criteria for an SNF stay from October 16, 2020, through November 16, 2020. The enrollee's main diagnosis is debility, and he was treated for a full two months without showing substantial improvements to justify daily therapies in an inpatient setting. The enrollee did not have any nursing needs for an SNF stay. The enrollee was stable with no new medical problems, had no documented nursing needs with functional level and did not need daily skilled therapies in an inpatient setting. The enrollee's rehabilitation needs could have been met in a long-term care facility with infrequent therapies. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for SNF services provided from October 16, 2020, through November 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lustatercept.

You asked the Plan to pre-approve Lustatercept. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Lustatercept. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. The documentation does not support that the requested use is supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the enrollee does not meet criteria for the requested drug. Our physician reviewer found the enrollee has Myelodysplastic syndrome (MDS).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lustatercept have not been met. Therefore, we decided that the Plan does not have to pre-approve Lustatercept.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that your blood sugars have been erratic and it's inconvenient to finger stick several times a day. The Plan denied your request. The Plan says you do not meet the criteria for coverage.
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 shows that you take insulin once per day and do not adjust your insulin dose based on glucose testing results. 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 Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Revlimid tablets.
You asked the Plan to pre-approve Revlimid tablets. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Revlimid tablets are not covered under the enrollee's Medicare 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 Revlimid tablets.
Benefits for Revlimid tablets 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tooth extraction for tooth 27.
You asked the Plan to pre-approve these services. You say that you would like the services to be covered. The Plan denied your request. The Plan says the services are 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 tooth extraction for tooth 27.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve these services. You say that the enrollee has an ongoing wound that is healing. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy and occupational therapy (PT/OT) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON PT/OT services. You say that there are no network providers who can furnish the services the enrollee requires. The Plan denied your request. The Plan says all necessary care can be provided by a 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 provider at issue in this case is not a network provider with the Plan. 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 OON PT/OT services. Our reviewer says that the documentation does not support that the requested OON provider is medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 95-year-old female with a decline in mobility due to right hip pain.
There is no documentation that there is anything unique about the enrollee's condition which would make it medically necessary to see the OON provider. Based on the medical records provided, there is documentation that the in-network provider can meet the Standards of Care required for treatment of the enrollee's condition. Since there is no apparent network deficiency, criteria for referral to the OON provider are not met. 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 OON PT/OT services have not been met. 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 the OON PT/OT services. Therefore, we decided that the Plan does not have to pre-approve physical therapy and occupational therapy (PT/OT) to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 24, 2020, through December 9, 2020, and from December 14, 2020, through December 24, 2020.
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment should have been made for these dates. The Plan denied your request. The Plan says it was determined that daily skilled care was required from 12/10/2020 to 12/13/2020. All other dates in question involved noncovered custodial care.
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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from November 24, 2020, through December 9, 2020, and from December 14, 2020, through December 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical procedure provided on October 2, 2020, billed with code 28192.

You asked the Plan to pay for the surgical procedure as billed. You say that the records support that this claim should be paid. The Plan denied your request. The Plan says this code 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 28192 is Removal of foreign body, foot, deep. 

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 the surgical procedure as billed. Our reviewer says that the documentation does not support this code. Our physician reviewer found the medical records does not include sufficient documentation to validate that the billed services were provided. Coding guidance states the following: "for a Puncture wound of the foot with an imbedded foreign body is to be coded as 28190 (removal of foreign body, foot; subcutaneous) - if an incision is made through the skin and into the subcutaneous tissues and closure is needed."

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 surgical procedure as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical procedure provided on October 2, 2020, billed with code 28192.