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

We decided that the Plan does not have to pre-approve an FDG positron emission tomography (PET) scan.

You asked the Plan to pre-approve the PET scan. You say that this is a scheduled procedure. You say that they are looking for potential Myeloma in lab work that was received. The Plan denied your request. The Plan says the enrollee does not have biopsy proven or strongly suspected multiple Myeloma.

The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. Medicare rules say that one FDG PET study is covered for beneficiaries who have cancers that are biopsy proven or strongly suspected based on other diagnostic testing when the beneficiary's treating physician determines that the FDG PET study is needed to determine the location and/or extent of the tumor. 

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. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has monoclonal gammopathy. Our physician reviewer found that there is no diagnosis of Myeloma as a marrow biopsy has not been done.

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 an FDG positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an anti-reflective coating (V2750) provided on May 11,
2021.
You asked the Plan to pay for an anti-reflective coating. You say that you are unable to pay this bill. You also
say the Plan said they would pay the bill. The Plan denied your request. The Plan says you exhausted your
benefit, and you are responsible for the remaining balance.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says that have a $100 allowance for supplemental eyewear every year.
We looked at the file and the Plan's rules. The records show you exhausted your $100 maximum allowed
benefit on May 11, 2021. The records also show that you purchased deluxe lenses at an allowed amount of $25
and spherocylinder bifocal lenses at an allowed amount of $37.50 for each lens. You received the total allowed
amount of $100 ($25 + $37.50 + $37.50 = $100). Based on this information, we decided that the Plan's rules for
coverage of an anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to
pay for an anti-reflective coating (V2750) provided on May 11, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus.
You asked the Plan to pre-approve a tier exception. You say that this medication is medically necessary. The
Plan denied your request. The Plan says that tier exceptions are not available for drugs covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D
drugs.
The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for
coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to preapprove
a tier exception for Tacrolimus.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at 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 based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an automatic blood pressure monitor.

You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says over the counter purchases are not covered under any condition.

The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. 

The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve an automatic blood pressure monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for
the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says the services can be safely received in other settings, for example: a skilled nursing
facility, home with home health services or home with outpatient therapy.

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 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 lumbar spine surgery. 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, and 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. There is not a
reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a new patient office visit (99203) provided on April 6, 2021.
You asked the Plan to pay for a new patient office visit. You say that this is supported in the records. The Plan denied your request. The Plan says this was not a new patient office visit.
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 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. We find that CPT code 99203 is not supported in the medical record. Specifically, the record shows that the enrollee was previously seen by this provider in October of 2019, meaning the enrollee received a professional service from the provider in the previous 3 years and is not a new patient. Based on this information, we decided that Medicare rules for coverage of a new patient office visit have not been met. Therefore, we decided that the Plan does not have to pay for a new patient office visit (99203) provided on April 6, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the full course of treatment in the hospital has not been completed.
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 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 a stroke. 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, and 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. There is not a reasonable expectation that this 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is still being studied to determine safety and efficacy.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve nonemergency transport taxi (A0100) beyond the Plan's
30-trip limit.
You asked the Plan to pre-approve additional routine transportation beyond the Plan's trip limit.. You say that
you require additional transportation to go to your medical appointments. The Plan denied your request. The
Plan says you have exhausted your routine transportation benefit and therefore additional transports are not
covered.
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 30 trips per year.
We looked at your request, the records in the case file, and the rules. The Plan provided documentation
showing that 30 routine transportation trips have already been covered for the year 2021. 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 nonemergency transport taxi
(A0100) beyond the Plan's 30-trip limit.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot inserts (L3000). You say that you feel you shouldn't have to pay for the prescribed orthotics because they did not help your leg and foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0858) and accessory battery (CPT code K2363), power seating system (CPT code K1002), seat cushion (CPT code K2608), headrest (CPT code E0955), center mount power elevating leg rest/platform (CPT code E1012), power wheelchair electronic connection (CPT code K2311), manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (CPT code K1028 X2), for the enrollee.

You asked the Plan to pre-approve the DME. You say that the enrollee is having a hard time getting around their apartment. You state the enrollee has morbid obesity and knee arthritis and it is making it difficult for you to get around your apartment and outside as well. The Plan denied your request. The Plan says the enrollee reported to be able to use a four (4) wheeled walker for mobility within the home and use a scooter outside of the home. The Plan states the enrollee reported via telehealth visit at the end of July that they are having additional functional issues, there is no objective evaluation. The Plan states the information does not support that criteria are met, as the enrollee uses a wheeled walker in the home and have a scooter for outside use.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve the power wheelchair (CPT code K0858) and accessory battery (CPT code K2363), power seating system (CPT code K1002), seat cushion (CPT code K2608), headrest (CPT code E0955), center mount power elevating leg rest/platform (CPT code E1012), power wheelchair electronic connection (CPT code K2311), manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory (CPT code K1028 X2), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81407 and 81408) provided
to the enrollee on February 8, 2021.

You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your
request. The Plan says the genetic testing was not ordered/approved by the enrollee as per the outreach
response spoke with the enrollee and the enrollee said they do not know the referring physician.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of the genetic testing have not been met. All diagnostic x-ray tests,
diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the
beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical
problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not
ordered by the physician who is treating the beneficiary are not reasonable and necessary. Therefore, we
decided that the Plan does not have to pay for the genetic testing (CPT code(s): 81407 and 81408) provided to
the enrollee on February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this treatment is considered safe and effective, as supported by its clinical benefits to patients, continued medical professional adoption, and strong clinical evidence with numerous peer-reviewed studies. The Plan denied your request. The Plan says the services are considered experimental and investigational.
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 surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 
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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies
(CPT code(s): K0554NU and K0553NU), for the enrollee.
You asked the Plan to pre-approve the diabetic supplies. You say that it is medically necessary based on other
general symptoms and signs. The Plan denied your request. The Plan says the Medicare rules have not been
met. The Plan states a standard home blood glucose monitor appears appropriate for the enrollee's current blood
glucose testing needs.
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 is not insulin-treated
with multiple (three or more) daily injections of insulin or a Medicare-covered continuous subcutaneous insulin
infusion (CSII) pump. The enrollee's insulin treatment regimen does not require frequent adjustment by the
beneficiary on the basis of BGM or CGM testing results. Within six (6) months prior to ordering the CGM, the
treating practitioner has not had an in-person visit with the enrollee to evaluate their diabetes control. As the
continuous glucose monitor cannot be approved, the request for the supplies also, cannot be approved as
reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of the
diabetic supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve the
therapeutic continuous glucose monitor and supplies (CPT code(s): K0554NU and K0553NU), for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on April 28, 2021.
You asked the Plan to waive the copayment for ambulance services. You say that if another company had come you would not owe a copayment and request that the copayment be waived. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment for ambulance services. You have been asked to pay a $200 copayment for ambulance services. Ambulance services fall within the ambulance services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on April 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (E1230).

You asked the Plan to pre-approve a power operated vehicle. You say that this item is necessary to return the enrollee to her prior level of functioning. The Plan denied your request. The Plan says this item is not medically necessary.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (E1230).