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

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.

You asked the Plan to pre-approve the compression stockings. You say that compression stockings are standard
of care for patients with pain and edema in the extremities. The Plan denied your request. The Plan says
compression stockings are not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are
non-covered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression
stockings identified with code A6533.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. 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 septic shoulder joint. She was transferred to a skilled nursing facility on 5/15/21. 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, in an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care 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: 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 services are medically necessary. The Plan denied your request. The Plan says coverage rules have not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving 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 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the PGxOne Plus testing provided on November 17, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is 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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that PGxOne Plus is a 60+ gene pharmacogenomics test that can provide insight into how patients may respond to certain medications. The documentation does not support that pharmacogenomics testing of 60+ genes was medically reasonable and necessary for the enrollee in this case. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the PGxOne Plus testing provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on June 25, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not include a valid physician order or laboratory results.

The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services in the medical record, is required for Medicare-covered laboratory services.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, there is no evidence that the physician ordered quantitative testing. There is no evidence that qualitative testing was ordered or rendered. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on June 25, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied your request. The Plan says rules for SNF care have not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the beneficiary is an 89-year-old male with multiple medical conditions. In this case, there are no identifiable skilled therapy service needs and no identifiable skilled nursing service needs. In addition, the beneficiary does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for 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 admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the sclerosant injection for the treatment of veins provided on December 3, 2020
You asked the Plan to pay for the sclerosant injection. You say that the sclerosant injection for the treatment of veins provided on December 3, 2020 was medically necessary. The Plan denied your request. The Plan says the sclerosant injection for the treatment of veins provided on December 3, 2020 was 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 pay for the sclerosant injection. Our reviewer says that the sclerosant injection for the treatment of veins provided on December 3, 2020 was not medically necessary. Our physician reviewer found the documentation does not support the medical necessity of the sclerotherapy treatment performed on December 3, 2020. It is documented that the enrollee had no venous reflux and the photos demonstrated visible reticular veins and telangiectasia with no edema. 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 sclerosant injection have not been met. Therefore, we decided that the Plan does not have to pay for the sclerosant injection for the treatment of veins provided on December 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96401) provided June 26, 2020.

You asked the Plan to pay for the chemotherapy administration. You say that the services were medically necessary. The Plan denied your request. The Plan says the most appropriate CPT code was not billed.

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 96401 is chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic. 

We find that CPT code 96401 is not supported in the medical record. Specifically, this administration would more appropriately be billed using CPT code 96372. Based on this information, we decided that Medicare rules for coverage of the chemotherapy administration have not been met. Therefore, we decided that the Plan does not have to pay for chemotherapy administration (96401) provided June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration described by current procedural terminology (CPT) code 96417 provided on August 24, 2020.
You asked the Plan to pay for CPT code 96417. You say that the medical records support the billing of CPT code 96417 provided on August 24, 2020. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 96417 provided on August 24, 2020.
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 96417 is Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (List separately in addition to code for primary procedure). 
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 CPT code 96417. Our reviewer says that the medical records do not support the billing of CPT code 96417 provided on August 24, 2020. Our physician reviewer found both remicade infusions are listed as occurring over 3 hours. Therefore, CPT code 96417 would not be the appropriate code for this infusion. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 96417 have not been met. Therefore, we decided that the Plan does not have to pay for the chemotherapy administration described by current procedural terminology (CPT) code 96417 provided on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and supplies.
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor and supplies. You say that the item 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 the criterion that equipment have an expected lifetime of at least 3 years was added to the regulatory definition of DME at 42 CFR 414.202 in 2012. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor and supplies.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3 stage surgery of the cervical spine.

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient has C5-6 severe stenosis and other areas of mild to moderate stenosis. A C5-6 anterior cervical discectomy and fusion (ACDF) and a second stage posterior surgery is all that 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve a 3 stage surgery of the cervical spine.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14-day device.

You asked the Plan to pre-approve a Freestyle Libre 14-day device. You say that the item 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 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 you do not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14-day device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14-day device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve carpal tunnel surgery (64721).
You asked the Plan to pre-approve this service. You say that this service is medically necessary. The Plan denied your request. The Plan says this service is 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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that you were being treated for right carpal tunnel syndrome, cubital tunnel syndrome. You reported the right arm symptoms are getting much worse and you feel that you are ready for surgery. You have indicated that all fingers will go numb and the pain will start at the elbow and radiate down the arm. It will cause night pain. The exam of the right wrist/hand reveals no atrophy. There is a diminished sensation to light touch in the volar tips of all fingers of the right hand. Tinel's sign test is positive at the medial nerve of the wrist. Phalen's sign test is positive. There is a diminished grip. The exam of the right elbow reveals positive Tinel's of the ulnar nerve. However, detailed documentation is not evident regarding trial and failure of recent, reasonable and comprehensive less invasive conservative care measures. There is no documentation of trial and failure of splinting and/or a corticosteroid injection to the right carpal tunnel. Furthermore, electrodiagnostic testing was not provided for review to corroborate the carpal tunnel pathology on the right side. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to literature. Therefore, the request for right carpal tunnel surgery is not medically reasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve carpal tunnel surgery (64721).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg and associated supplies and accessories to be provided by an OON provider.
You asked the Plan to pre-approve a prosthetic leg and associated supplies. You say that the requested item is necessary for the enrollee. The Plan denied your request. The Plan says rules for OON care have not been met.
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 prosthetic leg and associated supplies and accessories to be provided by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick.
You asked the Plan to pre-approve an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick. You say that the requested expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are medically necessary. The Plan denied your request. The Plan says the requested expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick 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 an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick. Our reviewer says that the requested expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that the enrollee has a covered indication for the requested expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick per Local Coverage Article A52504. Records indicate the enrollee has 4/5 strength in her upper extremities and is independent with eating; her upper extremity strength and function are adequate for her to be able to control the power options using their own switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377), expandable controller harness (E2313), and electro connect (E2311) to control power tilt, recline and power elevating leg rests through the joystick.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 27, 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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results.

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on October 15, 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 the denial of payment for this testing is correct, because predictive screening testing is not a Medicare benefit.

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 tests at issue in this appeal, lab tests, were requested for screening purposes. Medicare does not cover these tests for screening purposes. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on October 15, 2020.