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

We decided that the Plan does not have to pay for lab services (81206, 81235, 81321) provided April 30, 2021.
You asked the Plan to pay for the lab services. You say that the service was medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed.
The Plan must follow Medicare rules. Medicare rules say that when a laboratory assays two or more genes in a patient in parallel, those two or more genes will be considered part of the same panel. We looked at the file and Medicare rules. Multiple codes were billed for a single panel in this case. 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 (81206, 81235, 81321) provided April 30, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services (G0483) provided on March 4, 2021.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not billed with the appropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code G0483 is not supported in the medical record. Specifically, this claim was billed with a laboratory place of service code while the record indicates that the member's face-to-face service was rendered in an office setting. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services (G0483) provided on March 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray examinations of the tibia and fibula; two views (73590 x 2) rendered by the out-of-network (OON) provider on August 18, 2021.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.
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 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 x-ray examinations of the tibia and fibula; two views (73590 x 2) rendered by the out-of-network (OON) provider on August 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient naturopathic medicine services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the outpatient services. You say that the codes are covered codes and you were advised that the codes were covered. 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. Non-emergent services with non-contracted providers require prior authorization before services being rendered. Naturopathic medicine is not a Medicare covered 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 the outpatient naturopathic medicine 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 continuation of SNF care, from February 15, 2022,
forward.

You asked the Plan to pre-approve SNF care. You say that you are on your deathbed and cannot be moved. The
Plan denied your request. The Plan says your request does not meet Medicare guidelines because there are no
noted daily skilled complex nursing or therapy needs which would meet the guidelines for continued SNF
services. The Plan states while you may benefit from continuing physical, occupational, and speech therapy,
the records do not support the need for daily therapy on an inpatient basis.

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 as of February 13, 2022, you did not require
any skilled nursing or rehabilitation services on a daily basis. You were not expected to make measurable gains
within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with
mobility or activities of daily living (ADLs). You did not require skilled therapy to establish a safe and
effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient
basis, at a SNF level of care as of February 13, 2022. You did not have any parental medications, complex
wound care or nutrition given via a feeding tube. You received skilled care and improved; however, your
functional improvement had plateaued by February 13, 2022, and you did not require any further inpatient
skilled rehabilitation services. Your function was at or near your prior level of function and you could be
discharged to a lower level of care for further services. As of February 13, 2022, you required custodial
services. The denial for further inpatient skilled care is upheld.

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 continuation of SNF care, from February 15, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) and deep sedation/general anesthesia (D9222 and D9223).
You asked the Plan to pre-approve the extraction and deep sedation/general anesthesia. You say that you need to have your tooth removed due to a serious pain. You also say that you need this tooth removed before it causes a situation with your blood. The Plan denied your request. The Plan says these services are not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a surgical extraction (D7210) and deep sedation/general anesthesia (D9222 and D9223).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eliquis.
You asked the Plan to pre-approve Eliquis. The Plan denied your request. The Plan says this is not a covered
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 Eliquis.
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 inpatient rehabilitation following a complete hip replacement and broken leg. You say that the longer you stay in bed the harder and longer rehabilitation will be. You say that skilled nursing facility services are not appropriate because physician oversight is required. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee's care can safely be provided in a less intensive 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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for a femur fracture after recent total hip replacement. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of AmDrop.

You asked the Plan to pre-approve the requested services. You say that your arm hurts bad. The Plan denied
your request. The Plan says the injection is not the standard of care.

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 you have a history of bilateral shoulder pain due to primary osteoarthritis of the shoulder.
A review of the current medical literature indicates that this service is considered experimental and
investigational as it is not identified as widely used and generally accepted for the proposed use as reported in
nationally recognized peer-reviewed medical literature. The Medicare criteria for reasonable and necessary are
not met as it has not been shown to be safe and effective in long term studies. There is a lack of evidence to
support that joint injection of human amniotic fluid is considered experimental, investigation, and or unproven
for all indications, including the treatment of osteoarthritis.

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 an injection of AmDrop.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractor office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve an office visit. You say that you have seen this provider prior and would like to continue to see this provider. The Plan denied your request. The Plan says a list was given to the enrollee of chiropractors accepting new patients. Therefore, service for an out-of-network provider is denied.

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 a chiropractor office visit to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530, A6533, and A6539.

You asked the Plan to pre-approve the compression stockings. You say that this is medically necessary. The Plan denied your request. The Plan says these items are not listed as a covered benefit.

The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530, A6533, and A6539 are noncovered because they do not meet the statutory definition of a surgical dressing.

Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530, A6533, and A6539.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services (procedure code 97110) provided
to the enrollee on December 11, 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 Current Procedural Terminology (CPT) code 97110-GP CQ, KX (4 units) remains not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

Providers must report services with the appropriate CPT code.

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 a Physical Therapy Assistant
performed services in the home setting. For services performed in the home, a CPT code should not be
reported. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report.

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 physical therapy services (procedure code 97110) provided to the enrollee on December 11,
2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.

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 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 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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve deep sedation (D9222 and D9223) and a coronectomy
(D7251) provided by an out-of-network provider.
You asked the Plan to pre-approve deep sedation and a coronectomy. You say that you need this procedure
done because it's too risky to extract the tooth. The Plan denied your request. The Plan says the requested
dental work is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve deep
sedation (D9222 and D9223) and a coronectomy (D7251) provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a chiropractic office visit to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a chiropractic office visit. You say that the enrollee has increased pain and needs to see a specialist. The Plan denied your request. The Plan says there a specialist in-network that the enrollee can see.

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 a chiropractic office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm (J0172).
You asked the Plan to pre-approve Aduhelm. You say that it is your medical opinion that initiating treatment
with Aduhelm for this enrollee is medically reasonable and necessary, and that the procedures required for its
administration should be covered. The Plan denied your request. The Plan says Aduhelm does not meet
medical necessity criteria because the requested Part B Drug is considered experimental and investigational.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for Food and
Drug Administration (FDA) approved 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 Aduhelm. Our reviewer says that
Aduhelm (J0172) is not medically reasonable and necessary for the enrollee. Our physician reviewer found
Aduhelm is FDA-approved for the treatment of Alzheimer's disease in patients with mild cognitive impairment
or mild dementia stage of the disease. Our physician reviewer also found that the use is not listed as not
indicated, not supported, or not recommended in any of the compendia.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have
to pre-approve Aduhelm (J0172).
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 IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee can safely receive the services needed 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's medical conditions are reported to stable to treat with outpatient medications with no issues that require a physician's evaluation three or more times per week. The enrollee does require physical therapy and occupational therapy services but does not require an intensive inpatient rehabilitation therapy program. Continued care at the skilled nursing facility level appears to be appropriate in this case. 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.