Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that your father has cancer, several falls, and experiences weakness. The Skilled Nursing Facility will help my father gain strength to safely move small distances. The Plan denied your request. The Plan says that your father does not have any skilled physical therapy or occupational therapy daily needs and comfort care measures have been ordered. Services can be provided at a lower level of care.

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 the requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does require skilled therapy services daily at a skilled nursing facility to restore function and avoid further decline or complications. Admission to a skilled nursing facility for inpatient rehabilitation services is medically appropriate.

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the cup holder (CPT code K0108).

You asked the Plan to pre-approve the cup holder. You say that the item is necessary. The Plan denied your request. The Plan says the item is not covered by Medicare or the Plan.

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 the cup holder (CPT code K0108).
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 to help the enrollee become independent again. The Plan denied your request. The Plan says the services needed can be provided in another setting such as a skilled nursing facility, home health care 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 enrollee does not require treatment by multiple therapies. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99232-57 billed for date of service February 9, 2022.

You asked the Plan to pay for procedure code 99232-57. You say that this service was reported appropriately and should be paid separately. The Plan denied your request. The Plan says this service is not separately payable and is included in the global surgery period for code 69540 provided on the same date.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that the "-57" modifier is not used with minor surgeries because the global period for minor surgeries (10-day postoperative period) does not include the day prior to the surgery. Moreover, where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.

We find that CPT code 99232-57 is not supported in the medical record. Specifically, this service was provided on the same day as a minor surgery with a 10-day postoperative period. This means that the use of the -57 modifier is not appropriate in this case, and the service at issue is considered a routine preoperative service which is not billed in addition to the procedure. Based on this information, we decided that Medicare rules for coverage of procedure code 99232-57 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99232-57 billed for date of service February 9, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octreotide.

You asked the Plan to pre-approve Octreotide. 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 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 Octreotide. Our reviewer says that the services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of gastrointestinal bleed of unknown etiology. The Food and Drug Administration has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The elements of the coverage criteria 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 Octreotide have not been met. Therefore, we decided that the Plan does not have to pre-approve Octreotide.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for tenolysis, flexor tendon; palm OR finger, each tendon provided to the enrollee on June 15, 2022.

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 code is not supported in the records submitted.

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 26440 is "Tenolysis, flexor tendon; palm OR finger, each tendon."

We asked our coder 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 reviewer found that the enrollee was being treated for lesion of ulnar nerve left upper limb; trigger finger left index finger; carpal tunnel syndrome left upper limb; chondrocalcinosis; postprocedural status. He underwent a revision of left carpal tunnel release, left cubital tunnel decompression, left index flexor tendon sheath, and incision with tenolysis as indicated on 6/15/22. The surgery details cite there was tenosynovitis present and significant digital stiffness despite the A1 pulley release. Therefore, a tenolysis of the flexor digitorum superficialis tendon was performed. It was retracted from the wound at the level of the palm and adhesions were present adhering the tendon to the underlying flexor digitorum profundus and these adhesions were also released. Therefore, the records do support that CPT 26440: tenolysis, flexor tendon; palm OR finger, each tendon was rendered in this case.

We looked at this coder's review, the file, and Medicare rules. 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 tenolysis, flexor tendon; palm OR finger, each tendon provided to the enrollee on June 15, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute 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 your request for an IRF admission does not meet the requirements for approval.

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 your medical problems are stable and there are no complex nursing or rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the enrollee is far too medically complex for skilled nursing facility care. You say daily supervision and medical care by rehab physicians is required but is not available in the skilled nursing facility setting. The Plan denied your request. The Plan says based on Medicare guidelines, the IRF services requested do not meet the requirements for approval.

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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the medical record supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 IRF admission and services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after January 21, 2023.

You asked the Plan to pre-approve SNF care after January 21, 2023. You say that the continued admission to a SNF is medically necessary. The Plan denied your request. The Plan says the continued admission to a SNF 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 care after January 21, 2023. Our reviewer says that the requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. 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 after January 21, 2023, have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after January 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guidance Urinary Tract Infection (UTI) testing provided on 
July 5, 2022. 
 
You asked the Plan to pay for Guidance UTI testing. You say that this test was medically necessary and 
appropriate. The Plan denied your request. The Plan says this test is not covered per Medicare MolDX. 
 
Medicare rules say that molecular diagnostic laboratory tests are subject to the MolDX application, assessment, 
and approval process. Once this is complete, the test is assigned a reimbursement rate and a unique test 
identifier. 
 
 We looked at the file and Medicare rules. This test is listed in the DEX database as non-covered. This 
determination was made and is specific to the test at issue. Based on this information, we decided that 
Medicare rules for coverage of Guidance UTI testing have not been met. Therefore, we decided that the Plan 
does not have to pay for Guidance Urinary Tract Infection (UTI) testing provided on July 5, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Sprint percutaneous nerve stimulator. 
 
You asked the Plan to pre-approve Sprint percutaneous nerve stimulator. You say that the enrollee continues to 
suffer due to chronic intractable low back pain. The Plan denied your request. The Plan says there are no 
studies published evaluating the Sprint percutaneous nerve stimulator device. 
 
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 Sprint percutaneous nerve stimulator. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found this is an experimental/investigational approach to lower back pain 
which has not been the subject of a head-to-head comparison trial for the treatment of low back pain. The 
enrollee has evidence-based therapies available. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Sprint percutaneous nerve stimulator have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the Sprint percutaneous nerve stimulator.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve Xarelto. The Plan denied your request. The Plan says Xarelto is a self-
administered drug, and does not fall under Part B coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xarelto.  
 
  Benefits for Xarelto 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 pre-approve hyperbaric oxygen therapy (HBOT) (99183), full body, 
30 minutes (G0277). 
 
You asked the Plan to pre-approve HBOT. You say that the requested procedure is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the requested HBOT is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that hyperbaric oxygen (HBO) therapy is covered as 
adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with 
standard wound therapy and must be used in addition to standard wound care. 
 
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 HBOT. Our reviewer says that the 
requested HBOT is not medically necessary. Our physician reviewer found the provided documentation does 
not indicate the enrollee has failed an adequate course of standard wound therapy for at least 30 days. The reviewer found that the enrollee's vascular status was not optimized until January 23rd, 2023, and 30 days have 
not elapsed since then. Therefore, the reviewer found that the requested service is not medically reasonable or 
necessary at this time. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBOT have not been met. Therefore, we decided that the Plan does not have to 
pre-approve hyperbaric oxygen therapy (HBOT) (99183), full body, 30 minutes (G0277).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. 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 ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found a home ventilator is not medically 
necessary. This enrollee has a diagnosis of chronic obstructive pulmonary disease (COPD), although there are 
no pulmonary function tests to assess severity. Arterial blood gas (ABG) as an inpatient was consistent with 
chronic hypercarbic respiratory failure.  This may be a combination of COPD and obesity-hypoventilation 
syndrome. The enrollee reportedly was provided bilevel positive airway pressure (BiPAP) at home, but settings and compliance are not provided. This enrollee may benefit from BiPAP with average volume-assured pressure 
support (AVAPS) and a backup rate as an outpatient. This has not been shown to fail as an outpatient. 
Medicare does not cover a home ventilator when used as BiPAP. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF 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's functional status does not require intensive therapy to improve or 
maintain function. 
 
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 IRF admission and services.