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

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 6, 2021.
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 it is necessary for the enrollee to be transferred to an LTACH, and they cannot receive the necessary care in a skilled nursing facility. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 record indicates that that the enrollee is improving but still requires high flow oxygen and acute care services. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not
satisfied; the requested service cannot be recommended. 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: 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 LTACH care is necessary for the
enrollee to improve his condition and avoid unnecessary hospital readmissions. The Plan denied your request.
The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate
inpatient acute care and the LTACH would not provide a clinical advantage.
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 enrollee appears to be improving and responding to current treatment. Only short-
term additional acute care is supported and can be safely administered at the current facility. The enrollee does
not require services at the LTACH that are not already available and covered at the current facility. Transfer to
LTACH is not medically necessary as there would be no clinical advantage. Transfer to a lower level of care
can be considered soon when treatment has completed.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of an auricular peripheral nerve stimulation
device.
You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied
your request. The Plan says that electro-acupuncture devices used for stimulation of auricular acupuncture
points are non-covered.
The Plan must follow Medicare rules. Medicare rules say that auricular peripheral nerve stimulators are electro-
acupuncture devices which are not covered by Medicare. Therefore, we decided that the Plan does not have to
pre-approve placement of an auricular peripheral nerve stimulation device
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that a SNF admission is medically necessary. The
Plan denied your request. The Plan says a SNF admission is not medically necessary.
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 medically necessary. Our physician reviewer found that from a nursing
perspective, the enrollee received oral medications. The enrollee had stable vital signs. She had a wound vac to
her sacral wound. Regarding rehabilitation services, the enrollee received physical therapy (PT) and
occupational therapy (OT). The enrollee was at a standby assist/supervision to contact guard assist level for
functional mobility including gait to 2 feet with a rolling walker. The enrollee required varying assist with
activities of daily living. There are identifiable skilled nursing service needs. There are identifiable skilled
therapy service needs. However, the enrollee does not require skilled nursing or therapy services on a daily
basis. As a practical matter, this enrollee does not meet severity of illness or intensity of service criteria for an
inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that you are requesting an appeal regarding the denial of coverage for a Flexitouch pneumatic compression device. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty scooter.
You asked the Plan to pre-approve a heavy-duty scooter. You say that the records provided support the need for
the requested scooter. The Plan denied your request. The Plan says that the criteria for coverage have not been
met.
The Plan must follow Medicare rules. Medicare rules say that a POV is covered when the beneficiary's weight
is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% weight
capacity of the next lower weight class POV.
We looked at the file and Medicare rules. The case file shows that the scooter being requested is a heavy-duty
version with a weight limit between 301 and 450 pounds. The records show that the enrollee weighs 260
pounds. This is not greater than or equal to 95% of the weight capacity of the next lower weight class scooter.
Based on this information, we decided that Medicare rules for coverage of a heavy-duty scooter have not been
met. Therefore, we decided that the Plan does not have to pre-approve a heavy-duty scooter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device and accessory (E0675 and
E0673) provided on June 23, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that you would like reconsideration
because this device is not experimental. The Plan denied your request. The Plan says a PCD coded E0675 is
only used for peripheral artery disease.
The Plan follows Medicare rules. The rules state that a PCD coded as E0675 to treat peripheral arterial disease
is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for treatment of peripheral artery disease, regardless of how they are billed on the claim.
Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and accessory
(E0675 and E0673) provided on June 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the OON PET scan. You say that the requested PET scan is to evaluate disease status and treatment decisions at your facility. You say that if the PET scan is negative you will continue observation and that if it shows active disease you will start chemotherapy. The Plan denied your request. The Plan says there is not a gap issue and there are in-network providers available who can supply the requested service.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.
Therefore, we decided that the Plan does not have to pre-approve positron emission tomography (PET) services to be provided by an out-of-network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that you really need skilled nursing and therapy every
day. The Plan denied your request. The Plan says the denial of authorization for SNF care is correct.
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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not have daily skilled nursing needs
that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have
daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional
therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled
nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis
vaccine (Tdap) received on July 6, 2021.
You asked the Plan to pay for the Tdap vaccine. You say that you were told that you were overdue to get this
vaccine. The Plan denied your request. The Plan says the services received are not a covered benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Tdap vaccine.
The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to the Tdap vaccine.
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular
pertussis vaccine (Tdap) received on July 6, 2021.
Benefits for the Tdap vaccine may be available under Medicare Part D. Contact the Plan that administers Part
D benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for surgical services received from June 3,
2021, to June 10, 2021.
You asked the Plan to waive the copayment for the services. You say that you were not told about the
assessment of an outpatient hospital fee. The Plan denied your request. The Plan says the copayments were
applied correctly according to your benefits and the services rendered.
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 $100
copayment for outpatient surgery.
You have been asked to pay a $100 copayment for the services. the services falls within the outpatient surgery
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 surgical services received from
June 3, 2021, to June 10, 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 the records provided support the need for care in an
IRF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says
that the enrollee's needs can safely be received in other settings.
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 weakness, a fall, electrolyte abnormalities and cardiac arrest. 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: 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 is a high fall risk and inpatient rehabilitation is medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they 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 the enrollee's 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 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) with sensors
(K0553).
You asked the Plan to pre-approve a continuous glucose monitor and sensors. You say that you took a
Medicare questionnaire which said you qualify for the requested items. The Plan denied your request. The Plan
says rules for coverage for continuous glucose monitors and related supplies 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 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 continuous
glucose monitor and sensors have not been met. Therefore, we decided that the Plan does not have to pre-
approve a continuous glucose monitor (K0554) with sensors (K0553).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the FlowerAmnioFlo amniotic liquid allograft injection
(Q4177) and Restorigin injection (Q4192) derived from human amniotic tissue (stem cell) and associated
services provided from May 18, 2021 to May 26, 2021.
You asked the Plan to pay for the FlowerAmnioFlo amniotic liquid allograft injection (Q4177) and Restorigin
injection (Q4192) derived from human amniotic tissue (stem cell) and associated services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
rendered are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Stem cell transplantation is only covered for certain indications.
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 FlowerAmnioFlo amniotic liquid
allograft injection (Q4177) and Restorigin injection (Q4192) derived from human amniotic tissue (stem cell)
and associated services. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case. Our physician reviewer found the enrollee had back, leg, and knee pain
due to arthritis and neuropathy. The record sent by the provider indicates that the enrollee received this
treatment for management of his chronic pain. Medicare guidelines say that this item or service is covered
under certain specified conditions, such as certain types of leukemia and blood disorders. Per the Medicare
guidelines, the request is not medically necessary because arthritis and neuropathy are not covered conditions
for stem cell treatment. Therefore, the enrollee did not meet criteria for the services rendered.
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 FlowerAmnioFlo amniotic liquid allograft injection (Q4177) and Restorigin
injection (Q4192) derived from human amniotic tissue (stem cell) and associated services have not been met.
Therefore, we decided that the Plan does not have to pay for the FlowerAmnioFlo amniotic liquid allograft
injection (Q4177) and Restorigin injection (Q4192) derived from human amniotic tissue (stem cell) and
associated services provided from May 18, 2021 to May 26, 2021.