Persius/hicric huggingface dataset:
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 these services are medically necessary. The Plan
denied your request. The Plan says that your needs can be safely met 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. You
do not require the intensity of services provided at an IRF.
Specifically, you are not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. Our physician reviewer found that your condition does not meet Medicare criteria for IRF
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dexcom G5 Receiver (CPT code K0554).
You asked the Plan to pre-approve the item. You say that the item is necessary. The Plan denied your request. The Plan says the Medicare rules 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 inject insulin three or more times per day or are using a Medicare-covered continuous subcutaneous insulin infusion (CSII)
pump. Based on this information, we decided that Medicare rules for coverage of the item have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G5 Receiver (CPT code K0554).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15271), application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15275), and Revita, per square centimeter (CPT code Q4180), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your request. The Plan says the services are not medically necessary because the documentation does not support thirty (30) days of failed comprehensive wound care which includes a vascular assessment and correction if needed.
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 services. physician reviewer found the record indicates that the enrollee has a diabetic foot ulcer with diminished pedal pulses. The record does not indicate that the adequacy of circulation and oxygenation has been established. The elements of the coverage criteria are not satisfied. The requested service is not recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve the application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15271), application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area (CPT code 15275), and Revita, per square centimeter (CPT code Q4180), for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the infrared therapy (97026) provided on August 4, 2021.
You asked the Plan to pay for the infrared therapy. You say that the infrared therapy is medically necessary and
should be covered. The Plan denied your request. The Plan says infrared therapy is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light and/or
heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such
as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds
and/or ulcers of the skin and/or subcutaneous tissues.
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 infrared therapy. Our reviewer says that
the infrared therapy is not medically necessary. Our physician reviewer found the provided documentation does
not indicate that the criteria for coverage has been met. Therefore, the reviewer found that the infrared therapy
is not covered.
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 infrared therapy have not been met. Specifically, the file shows that infrared
therapy is a non-covered treatment. Therefore, we decided that the Plan does not have to pay for the infrared
therapy (97026) provided on August 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650), provided on August 24, 2021.
You asked the Plan to pay for a back brace. You say that the item is medically necessary. The Plan denied your
request. The Plan says they were unable to discover any evidence of an established relationship between the
member and the ordering physician.
The Plan follows Medicare rules. Medicare rules say that a supplier may not contact an individual by telephone
regarding the furnishing of a covered item except under specific circumstances.
We looked at the file and Medicare rules. The Plan states that this item may have been ordered by an
unsolicited outreach telephone call to the enrollee, and this request was not initiated by the enrollee or the
enrollee's treating physician. The record does not show that written permission was obtained to make contact
by telephone regarding the furnishing of this item. The record does not show that contact was initiated
regarding an item already furnished to the enrollee or another item furnished to the same enrollee within the
past 15 months. Based on this information, we decided that Medicare rules for coverage of a back brace have
not been met. Therefore, we decided that the Plan does not have to pay for a back brace (L0650), provided on
August 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the 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 the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray services provided on July 29, 2021.
You asked the Plan to pay for the office visit and x-ray 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.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the office visit and x-ray services provided on July 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the brain imaging, PET; metabolic evaluation (CPT code 78608), for the enrollee.
You asked the Plan to pre-approve the PET scan. You say that the service is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
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 PET scan. Our physician reviewer found the enrollee is noted to have a memory impairment/dementia. According to the applicable NCD, a PET/computed tomography (CT) of the brain is covered for use in the evaluation of dementia in patients who meet diagnostic criteria for both AD and FTD when additional requirements are met/satisfied. The records provided for review did not show that the enrollee meets diagnostic criteria for both AD and FTD. Nor did they show that the other requirements within the NCD for coverage of this service were satisfied. The requested study would not be eligible for coverage. 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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve the brain imaging, PET; metabolic evaluation (CPT code 78608), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on June 9, 2021.
You asked the Plan to waive the copayment for the CT scan of the abdomen and pelvis. You say that the services should be covered as you have had them before, and the copayments were $0. The Plan denied your request. The Plan says the cost-sharing had changed for 2021 and you were notified of the Plan changes at the start of the year, therefor the cost-sharing applied is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $105 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies. You have been asked to pay a $105 copayment for a CT scan of the abdomen and pelvis. The cost-sharing for these services changed from $0 to $105 in 2021 and is the reason you are now being assessed a copayment. CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the abdomen and pelvis (74177) provided on June 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to provide 2 additional occupational therapy visits or 9 additional physical therapy visits.

You asked the Plan to provide 2 additional occupational therapy visits and 9 additional physical therapy visits. You say that you need to continue therapy to improve your strength and functioning. The Plan denied your request. The Plan says further PT and OT is unlikely to be of benefit at this time.

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 provide 2 additional occupational therapy visits and 9 additional 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 requested additional therapy is not generally accepted as specific and effective therapy for the enrollee's condition.

The enrollee has had extensive therapy for this condition and it does not appear that the enrollee's functional level requires the ongoing unique skills of a professional therapist to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The enrollee can safely transition to a functional maintenance program with staff. The specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the enrollee's 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 2 additional occupational therapy visits or 9 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to provide 2 additional occupational therapy visits or 9 additional physical therapy visits.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy evaluation: low complexity (97161) provided September 13, 2021, and the echocardiography, transthoracic, real-time with image documentation (2D) (93306) provided September 16, 2021.
You asked the Plan to waive the copayment for the physical therapy evaluation and echocardiography. You say that these costs should be bundled into a $90 emergency room copayment because you were at the hospital. The Plan denied your request. The Plan says the copayments were applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered physical, occupational and speech therapy visit and a $250 copayment for each covered diagnostic procedure or test at a network outpatient facility.
You have been asked to pay a $40 copayment for the physical therapy evaluation and a $250 copayment for the echocardiography. The physical therapy evaluation falls within the Outpatient rehabilitation services benefit category and the echocardiography falls within the Outpatient diagnostic tests and therapeutic services supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy evaluation: low complexity (97161) provided September 13, 2021, and the echocardiography, transthoracic, real-time with image documentation (2D) (93306) provided September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99292) provided on July 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is 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.
In this case, the CPT Code Manual definition of code 99292 is "Critical care, evaluation and management of
the critically ill or critically injured patient; each additional 30 minutes (list separately in addition to code for
primary service)."
We find that CPT code 99292 is not supported in the medical record. Specifically, the records do not show that
an additional 30 minutes of critical care services were provided on the date of service in question. Code 99292
is to be used in addition to code 99291 when more than 30-74 minutes of critical care services have been
provided. 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 the critical care services (99292) provided on
July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services you received from an orthopedic surgeon on July 30, 2021, August 2, 2021, and August 30, 2021, and the Xiaflex injection you received on July 30, 2021.
You asked the Plan to waive the cost sharing for the orthopedic surgeon services and the Xiaflex injection. You say that you cannot find in your documentation where you owe these copayments. You also said that this cost sharing is over 60% of your monthly Social Security income. The Plan denied your request. The Plan says you were charged this cost sharing correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for services obtained from a specialist and 20% coinsurance for Medicare Part B drugs.
You have been asked to pay a $40 copayment for each of the orthopedic surgeon services and 20% coinsurance for the Xiaflex injection. The orthopedic surgeon services fall within specialist services benefit category. The Xiaflex injection is considered a Medicare Part B drug. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing for the services you received from an orthopedic surgeon on July 30, 2021, August 2, 2021, and August 30, 2021, and the Xiaflex injection you received on July 30, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life2000 System portable ventilator (E0466).
You asked the Plan to pre-approve a Life2000 System. You say that the requested device differs significantly from a BiPAP device. The Plan denied your request. The Plan says medical necessity rules for the requested device have not been met as a BiPAP device could be used instead.
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 Life2000 System. Our reviewer says that the requested item is not medically reasonable and necessary in this case. Our physician reviewer found that this system is not a true ventilator. It provides volume positive pressure oxygen assistance during activity, but it is not capable of providing full ventilatory support. There is inadequate evidence of efficacy in any lung
disease. The enrollee does not have a pulmonary diagnosis that would meet Medicare criteria for a home ventilator. 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 Life2000 System have not been met. Therefore, we decided that the Plan does not have to pre-approve a Life2000 System portable ventilator (E0466
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan of the face (70486) provided on May 27, 2021.
You asked the Plan to waive the copayment for the CT scan of the face. You say that the services should be covered, and you are only paying $25. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $100 copayment for Outpatient Diagnostic Tests and Therapeutic Services and Supplies.
You have been asked to pay a $100 copayment for a CT scan of the face. CT scans fall within the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan of the face (70486) provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from
March 23, 2021, to March 29, 2021.
You asked the Plan to waive the copayment for the inpatient hospital care. You say that the services should be
covered. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services
provided.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $160
copayment per day for days 1-5 for Inpatient hospital care.
You have been asked to pay an $800 copayment for 5 days of inpatient hospital care ($160 x 5 = $800). This
means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for inpatient hospital care provided from March 23, 2021, to
March 29, 2021.