Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve seven additional home health skilled nursing visits, four additional home health physical therapy visits, and fourteen additional home health occupational therapy visits for the enrollee.
You asked the Plan to pre-approve the additional visits. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not support the requested services as well as the enrollee's progress.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 additional visits. Our reviewer says that the requested additional visits are not medically reasonable or necessary. Our physician reviewer found that in this case, the documentation doesn't support that the enrollee requires additional skilled nursing services or skilled rehab services to provide treatment that is medically necessary. The enrollee does not require additional skilled nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, perform a maintenance program to maintain the the enrollee's condition and/or prevent deterioration. The enrollee has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. The authorized services should be adequate to establish a home exercise program. The requested home health 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 additional visits have not been met. Therefore, we decided that the Plan does not have to pre-approve seven additional home health skilled nursing visits, four additional home health physical therapy visits, and fourteen additional home health occupational therapy visits for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (49560) provided on March 24, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 
service. 
 
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, we have confirmed that code 49560 is a column II code to column I code 44620. This claim has 
not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing 
criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (49560) 
provided on March 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have type 2 
diabetes, get confused and cannot remember things. You state you must see an endocrinologist because you do 
not have a thyroid and your sodium levels are low. The Plan denied your request. The Plan says this request 
exceeds your benefit amount. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case.  
 
The 21st trip and beyond is not a covered benefit. Your 2021 EOC states that enrollees must pay a $0 
copayment for up to twenty (20) one-way trips to plan approved locations every year. Therefore, we decided 
that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81479, 81302, 81408, 81330, 81345 
and 81407) provided on October 15, 2020. 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this 
testing was medically necessary. The Plan denied your request. The Plan says Medicare Guidance says 
screening panels/testing without a valid medical disease diagnosis related to the health of the member are not a 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the laboratory services. Our reviewer says 
that the services in question, a series of genetic tests for rare genetic cardiac and pulmonary diseases, are not 
medically necessary. Our physician reviewer found the records do not include any clinical information about 
the member, or the reason for ordering these tests. 
 
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 laboratory services have not been met. Therefore, we decided that the Plan 
does not have to pay for the laboratory services (81479, 81302, 81408, 81330, 81345 and 81407) provided on 
October 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the therapeutic continuous glucose monitor and 
supplies. 
 
You asked the Plan to pre-approve the therapeutic continuous glucose monitor and supplies. You say that this 
equipment 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. 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 the enrollee does not use insulin 
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of 
the therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the therapeutic continuous glucose monitor and supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CxBladder testing provided on December 14, 2020.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0012M and 0013M are non-covered for CxBladder testing. We looked at the file and Medicare rules. In this case, code 0013M was billed for CxBladder testing. This is a non-covered code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the CxBladder testing provided on December 14, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of the thorax for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says repeat imaging is only supported once a year for this condition. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found the record indicates that 
the enrollee has idiopathic pulmonary fibrosis. The record indicates that the enrollee had a CT chest in March 
2021 that showed mild to moderate fibrosis. The records state that the enrollee is stable to improved in terms of 
symptoms. The records indicate that the CT scan is required as a precondition to the use of Ofev. The record 
does not provide any support for this statement. The provided records do not indicate the medical necessity or 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied. 

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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve CT scan of the thorax for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and supplies.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor and supplies. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria 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 the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor and supplies.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six (6) additional physical therapy visits (CPT code 97164).
You asked the Plan to pre-approve the physical therapy visits. You say that you do not own a pool with the treadmill to complete the exercises and the exercises cannot be done on land. You state if you cannot continue the services, you will need to start the process all over again a few months when you are not able to walk. You state that if you stop the therapy now, there is no way you will be able to continue. The Plan denied your request. The Plan says you are functionally stable and able to continue with a home exercise plan. The Plan states you are receiving repetitive exercise and do not require input from a skilled therapist.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. Therapy notes state that patient prognosis is limited by chronicity, fibromyalgia, coping mechanisms, fall history and polypharmacy. You may benefit from a follow up with her medical provider to address some of these issues. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve six (6) additional physical therapy visits (CPT code 97164).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedure coded as 97110 provided on March 15, 2021.
You asked the Plan to pay for the therapeutic procedure. You say that you would like these claims reprocessed based on the documentation provided. The Plan denied your request. The Plan says the documentation provided does not support the CPT code as billed.
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 97110 is therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.
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 therapeutic procedure. Our reviewer says that the documentation provided does not support the code as billed. Our reviewer found therapy visit documents a home visit performed by a physical therapy assistant. CPT 97110 is an inappropriate code to report for both a physical therapy assistant, and services performed in the home. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code to report. Therefore, this code would not be covered. 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 therapeutic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedure coded as 97110 provided on March 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the surgical and office services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services.. You say that the other two doctor's the enrollee was referred to a general surgeon, and the other is a rectal and colon surgeon. You state the doctor specializes in breast cancer and the enrollee's family wants them to see this provider for this treatment. The Plan denied your request. The Plan says there are providers in-network that can provide the services.
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 surgical and office services to be provided by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning November 4, 2021.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 these services.
Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee was admitted to the inpatient psychiatric hospitalization on October 9, 2021 with unspecified major neurocognitive disorder with behavioral disturbance. Based on the submitted records, it is not expected that he will improve in a reasonable period of time beyond the dates in question, as he is not showing any dangerousness to self or others and has no auditory or visual hallucinations. He has no aggressive behaviors and is not showing any acute threats to safety. He is cooperative and compliant with his medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care, rather than a lower level of care, beyond the dates in question as he does not have any suicidal or homicidal thoughts or abnormal behaviors. It does not appear that active treatment is taking place beyond the dates in question. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services beginning November 4, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 mg/ml subcutaneous injection for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no medical necessity to make a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has age related osteoporosis with high risk of osteoporotic fracture. The prescribing provider indicated that she was going to start Fosamax. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 mg/ml subcutaneous injection for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the chemotherapy administration (96401) provided on June 
28, 2021. 
 
You asked the Plan to pay for the chemotherapy administration. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate code 
for the services rendered. 
 
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 96401 is chemotherapy administration, subcutaneous or 
intramuscular; non-hormonal anti-neoplastic. 

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 chemotherapy administration. Our reviewer says that 
CPT code 96401 does not meet criteria for billing or reimbursement consideration. Our reviewer found the 
procedure report documents "Dosage Prolia 60 mg.  Left upper arm SQ" was given.  CPT 96401 is an 
inappropriate code to report for this service.  There is a more appropriate CPT 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 chemotherapy administration have not been met. Therefore, we decided that 
the Plan does not have to pay for the chemotherapy administration (96401) provided on June 28, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for SNF services provided from February 3, 2020, through February 9, 2020.
You asked the Plan to pay for SNF services. You say that the claim was billed within the appropriate timeframe. The Plan denied your request. The Plan says the corrected claim is past the allowed 12-month timeframe.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.
The record shows that a claim for SNF services was not filed until July 28, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for SNF services provided from February 3, 2020, through February 9, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on January 28, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the behavioral health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the behavioral health services provided on January 28, 2021 by an out-of-network (OON) provider.