Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from December 14, 2019 to December 16, 2019.
You asked the Plan to pay for the HIT services. You say that this should be covered due to medical necessity. The Plan denied your request. The Plan says this code is not valid for Medicare billing purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. CPT code S9500 has a status indicator of "I" in the Physician Fee Schedule. This means that the code is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (HIT) services provided from December 14, 2019 to December 16, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot orthotics provided on December 12, 2019.
You asked the Plan to pay for the foot orthotics. You say that this boot allowed you to walk. 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 pay for the foot orthotics provided on December 12, 2019.
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 the CGM. You say that you feel that this should be covered because it is painful for you to prick your fingers. The Plan denied your request. The Plan says you do not meet criteria for the use of a CGM.
The Plan must follow Medicare rules. Medicare rules say that CGMs are covered for enrollees with diabetes who require three or more injections of insulin per day with frequent adjustments needed based on test results. In this case, you have attested that you do not require insulin injections and take oral diabetes medications only. There is no other documentation to show that the criteria for this device are met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
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 you would like reconsideration as the IRF admission
is medically necessary. The Plan denied your request. The Plan says your records do not show that you have a
need for intensive rehabilitation or complex conditions which require physician supervision.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 you do not have any acute or medically complex events needing physician
supervision. You will not be able to fully participate due to your condition and your rehabilitation needs may
be met 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 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the bypass grafts (35566 and 35682), revision (35833) and
emblolectomy (34201).
You asked the Plan to pay for the surgery. 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 support the
services 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.
We asked our coder 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 surgery. Our reviewer says that the documentation was
reviewed and CPT codes 35566, 35883, 34201 and 35682 do not meet criteria for billing or reimbursement
consideration. Our reviewer found CPT codes 35566, 35883, 34201 and 35682 were not documented in the
operative report and cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the surgery have not been met. Therefore, we decided that the Plan does not
have to pay for the bypass grafts (35566 and 35682), revision (35833) and emblolectomy (34201).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a stress test (93351).

You asked the Plan to pre-approve stress test. You say that this is necessary to monitor your heart health. The Plan denied your request. The Plan says that you do not have a change in cardiac status.

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 stress test. Our reviewer says that the requested stress test is considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided, you have prior silent coronary ischemia, now revascularized coronary disease, no cardiac symptoms and no ischemia on your most recent stress echocardiogram more than 2 years ago. In this circumstance, the documentation supports the medical necessity for periodic stress testing in the absence of symptoms since you never had chest pain, even in the presence of severe coronary disease. Current guidelines endorsed by several national organizations do not consider stress testing more than 2 years from the prior exam inappropriate. Moreover, in this circumstance of hypertrophy and prior coronary revascularization the accuracy of exercise electrocardiography is significantly reduced compared to exercise stress testing with imaging (echo or nuclear).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stress test have been met. Therefore, we decided that the Plan has to pre-approve a stress test (93351).
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 services are 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. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 you were medically stable with no evidence of need for supervision by a physical
medicine and rehabilitation (PMR) Physician or needs acute rehab nursing care. You may benefit from further
physical therapy (PT) and occupational therapy (OT) but do not require an intensive therapy program. IRF
admission is not medically necessary based on your current functional status and medical stability.
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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a tertiary level office visit with the requested out-of-network provider.
You asked the Plan to pre-approve office visit. You say that the enrollee has a very serious and rare disease with only a few cases in the area, and this provider has a specialized unit that deals with the enrollee's disease. The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 office visit. Our reviewer says that the enrollee meets the Medicare criteria for treatment with the requested out-of-network provider. Our physician reviewer found the enrollee's condition is a rare disorder without clear guidelines for treatment. Patients are often referred to tertiary amyloid centers as a standard of care when available community level oncologists lack expertise. The Plan's recommended in-network provider is not listed as an expert in this disorder. Therefore, the referral to the requested provider is medically reasonable and 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 office visit have been met. Therefore, we decided that the Plan has to pre-approve a tertiary level office visit with the requested out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost shares for the medical services provided on June 28, 2019.
You asked the Plan to waive the cost shares for the services provided. You say that the front desk should have told you about the additional cost. The Plan denied your request. The Plan says the cost shares were applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).
The file shows that enrollee received a specialist office visit. A $35 copay was applied. The service falls within the practitioner services benefit category.
The enrollee received a shoulder x-ray. A $27.54 copay was applied. Because the amount is less than the $35 copay, the enrollee was charged the lesser amount. The service falls within the outpatient diagnostic tests benefit category.
The enrollee received a methylprednisolone injection. The allowed amount for the injection was $6.46. The enrollee was charged $1.29, which is 20% of the allowed amount. The service falls within the Medicare Part B prescription drugs benefit category.
The enrollee been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when she enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost shares for the medical services provided on June 28, 2019.
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 you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the IRF admission 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 above.
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 your nursing, medical and rehabilitation needs do not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your rehabilitation needs
can be met at a lower intensity 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 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 acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee needs rehab before going home. You say that the enrollee has been to the requested IRF before and did well. The Plan denied your request. The Plan says the records do not support the need for acute inpatient rehabilitation.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 enrollee was medically stable with no evidence of a need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. 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 a MyoPro electric orthotic device for the arm.
You asked the Plan to pre-approve the requested device. You say that the enrollee's disability can only increase from inevitable overuse syndrome to his right arm if it remains his only means for dexterity. The Plan denied your request. The Plan says functional electrical stimulation is indicated for spinal cord injury patients for walking.
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 requested device. Our physician reviewer found that the enrollee suffered a stroke in 2011 and now suffers from spastic left hemiparesis. Treatments since the stroke have included therapy, occupational therapy, electrical stimulation, and stretching. He continues to suffer from activities of daily living intolerance, and requires assist from family. There is no documented failure to respond to a body-powered lightweight device, and/or standard upper limb orthotics that are non-myoelectric. The requested device is at this time, a convenience item and deemed not medically necessary, for this enrollee's condition. 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro electric orthotic device for the arm.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) and psychotherapy service (99354) provided on February 7, 2020 by an out of network (OON) provider.
You asked the Plan to pay for an OON domiciliary or rest home visit and psychotherapy service. You say that these services were medically necessary. The Plan denied your request. The Plan says these services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) and psychotherapy service (99354) provided on February 7, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on September 12, 2019.
You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered 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 test at issue in this appeal, the genetic testing, 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 the genetic testing provided on September 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary to recover and return home. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF coverage under Medicare Part A benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office consultation and anesthesia services provided on November 25, 2019.
You asked the Plan to pay for the services provided. You say that the claim is wrongfully denied. The Plan denied your request. The Plan says the billed services cannot be verified.
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 99243 is office consultation for a new or established patient. We find that CPT Code 99243 is not valid for Medicare purposes under the physician fee schedule. Medicare uses another code for reporting of, and payment for these service. In this case, the CPT Code definition of code 00812 is anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy. The documentation shows that 45 units of code 00812 were billed for the services provided. We find that CPT code 00812 is not supported in the medical record. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the office consultation and anesthesia services provided on November 25, 2019.
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 the services are 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. 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 you are currently undergoing treatment at an acute care hospital (ACH) for CoViD-19. You were intubated/ventilated and subsequently received a tracheotomy. You appear to be slowly improving. There is no evidence that you require services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current ACH until such time no acute services are required. You can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs. 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.