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

We decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) receiver (K0554), and supplies (K0553).
You asked the Plan to pre-approve the CGM receiver and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says you are not insulin treated with multiple daily injections and your insulin regimen does not require frequent adjustment on the basis of blood glucose testing results.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess 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 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 CGM receiver and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (CGM) receiver (K0554), and supplies (K0553).
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 you would like reconsideration because the LTACH services are medically necessary. The Plan denied your request. The Plan says you can receive the same services at the current level of care.
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 medical record does not indicate that you require services that you are not currently receiving but that would be available at the LTACH facility. 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: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia for the enrollee.

You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that that the enrollee has not been on the oral bisphosphonate for sufficient time to judge it ineffective.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Prolia. Our reviewer says that Prolia is medically reasonable and necessary for the enrollee. The enrollee is has a diagnosis of osteoporosis. Her T score is -3.1. Denosumab (Prolia) is a humanized monoclonal antibody directed against the receptor activator of the nuclear factor-kappa B ligand (RANKL), which is a key mediator of the resorptive phase of bone remodeling. Denosumab decreases bone resorption by inhibiting osteoclast activity. Denosumab was approved by the Food and Drug Administration in 2010. It has shown benefit in cancer patients, patients with postmenopausal osteoporosis, and men with low bone mineral density. The approved dosage is 60 mg given subcutaneously every 6 months. Denosumab may be considered in certain patients with renal insufficiency, as impaired kidney function does not significantly affect the metabolism or excretion of the drug. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Prolia. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met. Therefore, we decided that the Plan has to pre-approve Prolia for the enrollee.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that you need SNF services to build up your strength. The Plan denied your request. The Plan says that you do not require complex daily nursing care that must be provided in a 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 pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF serivces. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuous glucose monitor (GM receiver (K0554) and supplies (K0553).

You asked the Plan to pre-approve the CGM receiver and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 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 assess 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 with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the CGM receiver and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuous glucose monitor (GM receiver (K0554) and supplies (K0553).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) and adjunctive prediagnostic
test (D0431) provided on December 1, 2020.

You asked the Plan to pay for the gingival irrigation and adjunctive pre-diagnostic test. You say that you
received a $400 bill for a deep cleaning that was approved. You also say that you have been told for 3 years
that you needed a deep cleaning. The Plan denied your request. The Plan says gingival irrigation is not listed as
a covered service. The Plan says adjunctive pre-diagnostic test is not listed as a covered service either.

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 gingival irrigation and adjunctive
pre-diagnostic test are not among those covered under this benefit. Therefore, we decided that the Plan does not
have to pay for the gingival irrigation (D4921 x 4) and adjunctive pre-diagnostic test (D0431) provided on
December 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for special anesthesia service (99100) provided on November 12, 2020.
You asked the Plan to pay for anesthesia. You say that you are requesting payment of this claim. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is always bundled for payment and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that payment for code 99100 is always subsumed by the payment for the services to which it is incident. We looked at the file and Medicare rules. This code is always bundled for payment and is not separately payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been met. Therefore, we decided that the Plan does not have to pay for special anesthesia service (99100) provided on November 12, 2020.
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 because the IRF services are medically necessary. The Plan denied your request. The Plan says the member's needs may be met in a different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 5, 2021.

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 services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. 

We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in a nursing facility setting and should have been billed with POS code 32. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
June 15, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.

The provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided 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 out of network physician services provided to the
enrollee on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the morphometric analysis provided on July 13, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is
bundled to another service billed on the same day.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
We find that CPT code 88377 was billed with code 81206 and 81207. The CPT code 88377 may be eligible for
payment when billed with this code combination. However, the claim does not indicate an appropriate modifier
was appended. Based on this information, we decided that Medicare rules for coverage of the services provided
have not been met. Therefore, we decided that the Plan does not have to pay for the morphometric analysis
provided on July 13, 2021
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 because the IRF services are medically necessary. The Plan denied your request. The Plan says the member's needs may be met in a different level of care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute 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 you would like reconsideration because the IRF services are medically necessary. The Plan denied your request. The Plan says the member's needs may be met in different level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The member's medical problems are stable. There are no complex nursing or rehabilitation needs. The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this member will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The
Plan denied your request. The Plan says that Medical studies haven't proven that this procedure is helpful for
treatment of your health problem.

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 requested services are not considered medically reasonable and necessary in this case. Bone marrow
aspirate remains experimental. More research is needed to show safety and efficacy of bone marrow aspirate
for use as bone graft material. Our physician reviewer found that the enrollee's condition does not meet criteria
for coverage of these services.

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 bone marrow aspiration for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes (A5500) provided on March 15, 2021, by a
supplier not enrolled in the Medicare program.

You asked the Plan to pay for diabetic shoes. You say that you are appealing the items at issue based on their
substantial personal cost. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for diabetic shoes (A5500) provided on
March 15, 2021, by a supplier not enrolled in the Medicare program.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99380) provided on March 27, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99380 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for this service. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (99380) provided on March 27, 2021.
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 this admission should be covered by the Plan. The
Plan denied your request. The Plan says Medicare coverage criteria are not 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 in the Medicare rules section. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine 
if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care 
is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the
complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay
with an interdisciplinary approach to rehabilitation care.

You were admitted for surgical management of an abdominal mass. Medical problems are stable. There are no
complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is no
documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable
expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy
program provided in an IRF.

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.