Persius/hicric huggingface dataset:
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 IRF care or will remain weak, will continue to fall, and will go back to the hospital. You say that you still have effects of coronavirus and need to fully recover and get your strength back. The Plan denied your request. The Plan says the enrollee's condition requires further evaluation and treatment at the acute care hospital. The Plan says that the guidelines for coverage of IRF care have 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 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 respiratory failure, COVID pneumonia, and multiple surgical procedures for perforated diverticulitis. The enrollee's 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 enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81493) provided August 31, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this service is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk assessment testing genomic screening panels for suspected or documented cardiovascular disease.
We looked at the file and Medicare rules. Genetic cardiovascular risk assessment testing is non-covered. Based
on this information, we decided that Medicare rules for coverage of the lab services have not been met.
Therefore, we decided that the Plan does not have to pay for lab services (81493) provided August 31, 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 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 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a fluid flow injection (Q4206) provided on November 30, 2020.

You asked the Plan to pay for a fluid flow injection. You say that this is a covered service. The Plan denied your request. The Plan says this is experimental for the enrollee's condition.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for a fluid flow injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is not approved for the enrollee's condition and is the subject of a warning.

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 fluid flow injection have not been met. Therefore, we decided that the Plan does not have to pay for a fluid flow injection (Q4206) provided on November 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554, K0553).
You asked the Plan to pre-approve a Freestyle Libre continuous glucose monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the requirements for coverage 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 perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (K0554, 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 the enrollee meets criteria for LTACH admission. The Plan denied your request. The Plan says the request for admission to an LTACH is not medically necessary.
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 that there is no documentation provided indicating medical necessity for admission to an LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for nursing facility care (99306) provided on April 23, 2021.
You asked the Plan to pay for nursing facility care. You say that the enrollee's hospice coverage had ended
before the service at issue. The Plan denied your request. The Plan says coverage of this service is the
responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on April 22, 2021. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for nursing facility care
(99306) provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intravascular flow-disruption device.
You asked the Plan to pre-approve an intravascular flow-disruption device. You say that the records provided support that the requested device is medically necessary. The Plan denied your request. The Plan says there are not enough current, published medical studies to show an intravascular flow-disruption device is effective for an endovascular repair of an intracranial aneurysm. The Plan says that this device is 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 an intravascular flow-disruption device. Our reviewer says that an intravascular flow-disruption device is not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has a anterior communicating artery aneurysm that measures 6.3 mm. The provided records are insufficient to demonstrate that the aneurysm satisfy the coverage criteria. The record provided does not establish the medical necessity and reasonableness.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an intravascular flow-disruption device have not been met. Therefore, we decided that the Plan does not have to pre-approve an intravascular flow-disruption device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services (44005) provided
February 9, 2021.
You asked the Plan to pay for the surgical assistant services. You say that the services were medically necessary. The Plan denied your request. The Plan says Registered Nurses are not eligible for surgical assistant payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.
In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical assistant services (44005) provided February 9, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 7, 2020, to May 16, 2020. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the secondary diagnosis of E43 was removed from the claim consistent with the documentation that was submitted.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the enrollee was admitted with a right hip fracture. Notations indicated that the enrollee was well developed and well nourished. He was using the PEG tube for medications only. A nutrition evaluation documented muscle wasting - no documentation of severe protein calorie malnutrition. The review has determined that the billed DRG and diagnosis codes were not correct in this case We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from May 7, 2020, to May 16, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (45400) provided June 15, 2021.
You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider was not a provider eligible for surgical assistant payment.
The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS. In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for surgical services (45400) provided June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist-hand-finger orthosis rendered on May 4, 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 there is no valid face-to-face evaluation.
The Plan must follow Medicare rules. The rules say that an in-person, face-to-face interaction between the
beneficiary and their treating physician is required prior to prescribing durable medical equipment. We looked at the file and Medicare rules. There is no documentation of a valid face-to-face encounter for these
services. 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 pay for the wrist-hand-finger orthosis rendered
on May 4, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluorouracil, Leucovorin, Oxaliplatin, and Irinotecan
(FOLFIRINOX) for the enrollee.

You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested treatment is not in the order recommended by the National Comprehensive
Cancer Network (NCCN) guidelines.

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 the drugs. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found this drug regimen is
only approvable with ECOG=0-1. This regimen is toxic.

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 drugs have not been met. Therefore, we decided that the Plan does not have
to pre-approve Fluorouracil, Leucovorin, Oxaliplatin, and Irinotecan (FOLFIRINOX) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zirabev, Carboplatin, Paclitaxel with Aloxi and Dexamethasone.
You asked the Plan to pre-approve the requested drug regimen. You say that these drugs are medically reasonable and necessary for the enrolle's condition. The Plan denied your request. The Plan says the requested drugs are not medically reasonable and necessary for the enrollee's condition.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 the requested drug regimen. Our reviewer says that the requested drug regimen is not medically reasonable and necessary for the enrollee's
condition. Our physician reviewer found the enrollee is a 65 year old who has been diagnosed with stage IC2 G2 ovarian cancer. In this case, the requested anti-cancer drug regimen is not FDA-approved for the enrollee's condition. In addition, the use of the requested drugs is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 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 drug regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Zirabev, Carboplatin, Paclitaxel with Aloxi and Dexamethasone
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on May 7, 2020.
You asked the Plan to pay for the dental items. You say that you no longer need the dental benefit that is provided with your plan. You also say that as a result, you would like a refund based on this year's dental amount. The Plan denied your request. The Plan says the claim was submitted beyond 12 months of the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for the dental items was not filed until June 2, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on May 7, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided to the enrollee on February 1,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the pickup site is not a covered destination.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.
Transport home from an elementary school would not be considered an emergent situation. 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 ambulance services provided to the enrollee on February 1, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve quick release axles for use with an approved power wheelchair.

You asked the Plan to pre-approve quick release axles. You say that the requested component should be approved. The Plan denied your request. The Plan says the quick release axles are not necessary for use in the home and cannot be covered by Medicare.

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 quick release axles. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documented medical need for the requested quick release axles.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of quick release axles have not been met. Therefore, we decided that the Plan does not have to pre-approve quick release axles for use with an approved power wheelchair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81493) provided September 18, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service was for screening purposes and is non-covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular risk assessment testing genomic screening panels for suspected or documented cardiovascular disease. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81493) provided September 18, 2020.