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

We decided that the Plan does not have to pay for a power seat elevation system (E2300) provided on March 30, 2021.
You asked the Plan to pay for a power seat elevation system. You say that the seat elevation function is necessary to promote your independence. The Plan denied your request. The Plan says rules for payment have not been met because the feature at issue is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pay for a power seat elevation system (E2300) provided on March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for acupuncture services provided from March 23, 2021, to April 6, 2021
You asked the Plan to reimburse you for acupuncture services (97813, 97814). You say that the treatments were for your headaches. The Plan denied your request. The Plan says the claim indicates a diagnosis of leg pain which is not one of the diagnoses in which acupuncture is covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the claim diagnosis code M79.605 pain in left leg, is not a covered diagnosis. Therefore, we decided that the Plan does not have to reimburse you for acupuncture services provided from March 23, 2021, to April 6, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient (CPT code 99443) provided on January 11, 2021, by an out-of-network provider.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says they have contacted your primary care physician (PCP) office to confirm the referral for the date of services. The Plan states the provider's office confirmed that the referral was only for January 28, 2021, and no referral for January 11, 2021; therefore, the Plan is allowing payment only for January 28, 2021.

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 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 the telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient (CPT code 99443) provided on January 11, 2021, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.
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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. The enrollee is undergoing a planned elective right knee surgery. She is medically stable with a past medical history of hyperlipidemia, chronic back pain, hypertension and diabetes. The planned procedure is not listed on the inpatient only list. The procedure is currently approved as an ambulatory procedure. There is no documentation provided to support the expectation the enrollee will require a greater than 2 midnight stay. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient hospital 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 acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cytopathology services rendered on March 3, 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 procedure code 88112 is not separately payable.

The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. 

The provider submitted a claim for procedure codes 88112 (cytopathology, selective cellular enhancement technique) and 88173 (cytopathology, evaluation of fine needle aspirate). Code 88112 is a column II code with a modifier indicator of 1 when billed with column I code 88173. Code 88112 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the cytopathology services rendered on March 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 25, 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 are 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 an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on January 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan denied your request. The Plan says the requested amount exceeds the limit listed by the plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 one-way trips per year. We looked at your request, the records in the case file, and the rules. The enrollee has used 54 out of 60 trips so
far. More than 60 trips cannot be allowed. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT code 78608), for the enrollee.

You asked the Plan to pre-approve the PET scan. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.

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 PET scan. physician reviewer found an FDG PET scan is considered reasonable and necessary in patients with a recent diagnosis of dementia and documented cognitive decline of at least 6 months, who meet diagnostic criteria for both Alzheimer's disease and Frontotemporal dementia. The enrollee does not meet the diagnostic criteria for these dementias. 

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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve brain imaging, PET; metabolic evaluation (CPT code 78608), for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the records do not support the need for daily therapy on an inpatient basis.
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 the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
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 recently had an above the knee amputation and needs therapy before returning home where she lives alone without any assistance, to rebuild strength and endurance. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee 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 an inpatient psychiatric admission from September 21, 2021, forward.
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that the continued inpatient psychiatric stay is medically necessary. The Plan denied your request. The Plan says based on Medicare guidelines, the inpatient psychiatric services you are requesting do not meet the requirements for approval beginning September 21, 2021.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a continued inpatient psychiatric admission. Our reviewer says that the continued inpatient psychiatric admission from September 21, 2021, forward is not considered medically reasonable and necessary in this case. Our physician reviewer found that this enrollee did not require inpatient mental health treatment beyond the dates in question as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. The enrollee was treated under an individualized treatment plan alluded to in the record. It appears that the services were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment from September 21, 2021, forward and could have been treated in a lesser restrictive setting as he was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a continued inpatient psychiatric admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient psychiatric admission from September 21, 2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on December 21, 2020.

You asked the Plan to pay for the services provided. You say that the ordering physician attested to the
coverage criteria on the requisition form. The Plan denied your request. The Plan says they are unable to
confirm the requirement of the genetic testing.

The Plan must follow Medicare rules. Medicare rules say that diagnostic tests must be ordered by the physician
who is treating the beneficiary.

We looked at the file and the rules. We find that the testing at issue is not supported in the medical record.
Specifically, there are insufficient medical records that clearly document the ordering physician's intent that the
test be performed. 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 Guardant360
testing provided on December 21, 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 need these services to regain your strength and independence. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can receive the care you need in an alternate setting.
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the
documentation does support a need for physical and/or occupational therapy, 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an INTELLIbed Tempurpedic with an adjustable base.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not considered durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an INTELLIbed Tempurpedic with an adjustable base
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Aduhelm.

You asked the Plan to pre-approve Aduhelm. You say that the requested treatment is a medical necessity for
the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the
requested treatment is experimental/investigational for all indications.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved
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 Aduhelm. Our reviewer says that the
requested drug is not medically reasonable and necessary in this case. Our physician reviewer found that the
requested use of Aduhelm is not FDA-approved for the enrollee's diagnosis. Aduhelm is indicated for the
treatment of Alzheimer's disease in patients with mild cognitive impairment or the mild dementia stage of the
disease. The documentation in the case file is not entirely consistent with a diagnosis of Alzheimer's disease.
The use is not supported by one of the major drug compendia or by clinical research that appears in a
Medicare-approved medical journal. The documentation is insufficient to demonstrate that Aduhelm is
expected to be safe and effective and otherwise reasonable and necessary, and at least as beneficial as existing
and available medically appropriate alternatives 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve treatment with Aduhelm.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September
23, 2021, onward.

You asked the Plan to pre-approve continued inpatient mental health care. You say that you need additional
mental health care and are not ready to return home. The Plan denied your request. The Plan says as of
September 23, 2021, the psychiatric care was no longer medically necessary at an acute inpatient level.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve continued inpatient mental health care.
Our reviewer says that the health plan's denial appears appropriate in this case. Our physician reviewer found
that based on the provided records, it is not expected that you will improve in a reasonable period of time
beyond the dates in question as you were not showing any dangerousness to self or others, auditory or visual
hallucinations, and you were without aggressive behaviors while not showing any acute threats of safety. You
are cooperative and compliant with medication. It does not appear medically necessary and reasonable to have
psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates
in question. It does not appear that active treatment is taking place beyond the dates already approved by the
Plan, and it does not appear that the services for the dates in question are reasonably expected or medically
necessary to improve your condition for the purpose of diagnosis. You can be treated in a less restrictive
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 continued inpatient mental health care have not been met. Therefore, we
decided that the Plan does not have to pre-approve continued inpatient psychiatric services from September 23,
2021, onward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors.
You asked the Plan to pre-approve Freestyle Libre sensors. You say that you are not ill and have no need to see a doctor. The Plan denied your request. The Plan says rules for coverage for continuous glucose monitors have 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 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 does not indicate that you have had an in-person visit with your treating physician to assess adherence to your CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Libre continuous glucose monitor sensors.