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

 We decided that the Plan does not have to pay for the lab services provided on November 11, 2020.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 11. However, the records do not show that the specimen was collected in an office setting. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on November 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for diabetic supplies (K0553) provided July 12, 2021.  You asked the Plan to pay for the diabetic supplies. You say that the diabetic supplies were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed items.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.    The record does not contain a valid physician order. The date on the claim (July 13, 2021) is before the date on the order (August 2, 2021). The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for diabetic supplies (K0553) provided July 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.  You asked the Plan to pre-approve the requested LDCT scan. You say that the requested imaging service is medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   We reviewed the file and the Medicare rules. We find that the criteria for coverage for the requested LDCT have not been met. Specifically, the record indicates that you are not between the ages of 55-77 years old.  Therefore, we decided that the Plan does not have to pre-approve a low dose computed tomography (LDCT) scan for lung cancer screening.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the acupuncture services. You say that you need the treatment on a continuous basis. You believe that seeing this provider on a continuous basis, he may be able to relieve the pain forever. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. The Plan approved the requested services with an in-network provider.  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 the acupuncture 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 admission to a skilled nursing facility (SNF).  You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met from the hospital setting.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing or therapy services on a daily basis. You do 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 the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Budesonide ER 9 mg tablet.  You asked the Plan to pre-approve Budesonide ER. You say that this drug is medically reasonable and necessary. The Plan denied your request. The Plan says this drug is not among those covered under the enrollee's medical benefit.  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 Budesonide ER 9 mg tablet.   Benefits for Budesonide ER 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: 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 IRF services are medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can safely be provided 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: 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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care. The enrollee does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which an LTACH may offer a therapeutic advantage. The Plan will continue to cover medically necessary care at the current facility.  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 there is no documentation provided indicating medical necessity for admission to a 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 they are 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a brand name roller walker for use in the home.  You asked the Plan to pre-approve this item. You say that the scooter does not fit into the bathroom and other places and you need the requested walker. The Plan denied your request. The Plan says Medicare does not pay for walkers or equipment of a special brand or type to use in the home. The Plan has provided coverage for a standard walker which your provider states does not help.   The Plan must follow Medicare rules. The rules say Medicare covers durable medical equipment only when it is reasonable and necessary. If durable medical equipment serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Both the appeal and the records show you have a scooter. A scooter serves the same purpose as the brand name walker requested. The Plan has graciously approved a standard walker, in addition to your scooter, which they are not required to do under Medicare guidelines. Therefore, we decided that the Plan does not have to pre-approve the brand name roller walker requested.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  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 continues to receive acute care services and these have not been denied. The medical records do not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility.  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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.  You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.  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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has chronic stasis ulcers due to chronic vascular disease. The review has determined that the enrollee does not have a covered indication for HBO therapy.  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 therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot inserts (L3000).  You asked the Plan to pre-approve foot inserts. You say that you are in pain and this would straighten your foot. 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 inserts (L3000).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).  You asked the Plan to pre-approve a total electric hospital bed. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).  You asked the Plan to pre-approve Dexcom G6 therapeutic CGM. You say that the Plan's preferred-brand monitor must be worn on the arm, but you want one that you can wear on your stomach or back. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because the Plan only covers Freestyle Libre therapeutic continuous glucose monitors (CGMs) and the record does not show that you have failed a trial with a Freestyle Libre device.  The Plan must follow Medicare rules. Medicare rules say that the Plan may limit coverage of durable medical equipment (DME) to certain brands. Your contract with the Plan says that the Plan only covers Freestyle Libre continuous glucose monitors unless an explanation is given for why another brand is medically necessary.  We looked at the file and Medicare rules. The Plan does not cover a Dexcom G6 brand therapeutic CGM. You may try the Plan's preferred brand of Freestyle Libre. Based on this information, we decided that Medicare rules for coverage of Dexcom G6 therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 therapeutic continuous glucose monitor (CGM).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines.  Our physician reviewer found the enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.  You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says you have no daily skilled nursing or therapy needs.  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. Continued SNF services beyond December 1, 2021, were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby assist to contact guard assist level with functional mobility. You required varying assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for physical therapy services in the home.  You asked the Plan to pay for the in-home physical therapy services. You say that you are not a home health agency. You say that the services being requested are medically necessary. You say that not allowing the enrollee to get these requested services could have a potential impact on his ability to regain maximum function and make measurable improvements that will be of practical value to him. You say that none of the Plan's home health agencies can perform weekly or as-needed basis nurse practitioner's/physician assistant's home visits and telemedicine. The Plan denied your request. The Plan says there are participating providers who can supply the in-home health care services being requested.  The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program.  Review of the file and Medicare records indicates that, while the requested provider may be enrolled in Medicare for certain services, they are not enrolled to provide the type of service being requested. The requested provider is not a certified home health agency, nor are they a physical therapy group that offers services in the home. Medicare does not have a benefit which covers a doctor's office billing for therapy provided in the home. The requesting provider is not enrolled in Medicare as a provider that is allowed to provide and be paid for the services being requested in this case. Therefore, we decided that the Plan does not have to pay for physical therapy services in the home.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve proton beam radiation therapy.  You asked the Plan to pre-approve the requested services. You say that this is the safest way to treat pelvic lymph nodes. The Plan denied your request. The Plan says the requested treatment is not the standard of care for prostate cancer.  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 requested services. Our physician reviewer found that there is no clear evidence that proton beam therapy for prostate cancer offers any clinical advantage over other forms of definitive radiation therapy. This enrollee is being offered pelvic/prostate radiotherapy. There are a few studies specifically describing proton therapy for pelvic radiation for prostate cancer. No comparison plan is provided for this enrollee showing an unacceptable non-proton-based plan. Routine use of proton therapy for pelvic/prostate radiation is not within accepted standards of medical practice. Therefore, the requested services are not medically necessary.  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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.