Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), and expandable controller harness (E2313).
You asked the Plan to pre-approve an electronic connection, expandable controller, and expandable controller harness. You say that the items are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that wheelchair accessories are covered when specific criteria are 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 an electronic connection, expandable controller, and expandable controller harness. Our reviewer says that the items are not medically necessary. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need a a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's strength in the upper extremities supports that the enrollee can control any power options on the power wheelchair through their own individual switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection, expandable controller, and expandable controller harness have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection (E2311), expandable controller (E2377), and expandable controller harness (E2313).
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 enrollee will be able to tolerate 3 hours of therapy per day and would benefit from IRF care. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.

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. While the enrollee may need physical and/or occupational therapy, there is no documented need for 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82300, 83655, 82175)
provided to the enrollee on July 13, 2020, for the enrollee.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We
looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage
of the laboratory services have not been met. The diagnoses submitted on the claims for the laboratory services
are not listed in the LCD and Policy Article as covered diagnoses. Therefore, we decided that the Plan does not
have to pay for the laboratory services (CPT code(s): 82300, 83655, 82175) provided to the enrollee on July 13,
2020, for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483, 80307) provided January 15, 2021.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services 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. 

We find that CPT codes G0483, & 80307 are not supported in the medical record. Specifically, the place of service listed on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 (G0483, 80307) provided January 15, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy visits (CPT code G0151 X
8), 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 enrollee's records do not support the need for a skilled physical therapist to make
more home visits at this time.
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 services. Our physician reviewer
found the records do not show that skilled therapy services are required to effectively provide treatment, care,
and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance
program to maintain the enrollee's level of function and/or prevent deterioration. The documentation reveals the
enrollee has had education on falls and safety. The enrollee is at a functional level that does not require
ongoing skilled 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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve home health physical therapy visits (CPT code G0151 X 8), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home ventilator.
You asked the Plan to pre-approve the home ventilator. You say that you would like reconsideration because the requested ventilator is medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the ventilator.
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 the home ventilator. Our reviewer says that the documentation in the medical record does not support that the ventilator at issue is medically necessary and reasonable for this member. Our physician reviewer found the review has determined that this patient does not have neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure consequent to
chronic obstructive pulmonary disease. 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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to waive the copayment for the emergency room visit provided on April 2, 2021.
You asked the Plan to waive the copayment for the emergency room visit. You say that you did not receive treatment and should not be responsible for the copayment. The Plan denied your request. The Plan says that you have been asked to pay the correct cost-sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not submit a full Evidence of Coverage (EOC). The Plan submitted one page of an EOC which did not include a contract name or number. This means we cannot verify if the copayment amount you are being asked to pay is correct. Therefore, we decided that the Plan has to waive the copayment for the emergency room visit provided on April 2, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 80307 and G0483)
provided to the enrollee on April 28, 2021, by an out-of-network provider.
You asked the Plan to pay for the out-of-network laboratory services. You say that the services should not
require pre-authorization since you are a participating provider. The Plan denied your request. The Plan says
this provider is out-of-network, the services were not referred by a network provider, and the services were not
urgent or emergent, nor were they approved in advance.
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 laboratory services (CPT code(s): 80307 and
G0483) provided to the enrollee on April 28, 2021, by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enhertu (fam-trastuzumab-deruxtecan-nxki) treatments.
You asked the Plan to pre-approve the Enhertu treatments. You say that it is felt that the treatment would be
beneficial for the enrollee. The Plan denied your request. The Plan says this is not a proven treatment and is not
covered for the enrollee's disease.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
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 the Enhertu treatments. Our reviewer
says that the requested treatment is not shown to be medically reasonable and necessary in this case. Our
physician reviewer found the record indicates that the enrollee has a diagnosis of HER2 positive periosteal
sarcoma. The Food and Drug Administration has not stated that the requested drug is indicated for the
enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the
use of the requested drug in the enrollee's clinical situation. No literature from Medicare approved cancer
journals were submitted for review. The elements of the coverage criteria are not satisfied.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81493) provided September 3, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular
risk screening assessment genomic testing panels for suspected or documented cardiovascular disease.
We looked at the file and Medicare rules. The service at issue is a cardiovascular risk assessment test and is not
covered. 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 (81493) provided
September 3, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional physical therapy (PT) visits (97164).
You asked the Plan to pre-approve additional PT visits. You say that you need more PT, and you feel it is
medically necessary. The Plan denied your request. The Plan says the requested services are not reasonable and
necessary.
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 additional PT 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 there is no documentation that the specialized skill, knowledge, and
judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your
current condition or to prevent or slow further deterioration. Provided therapy notes do not document a need for
further skilled physical therapy services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does
not have to pre-approve ten (10) additional physical therapy (PT) visits (97164).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing (CPT code(s): 81191, 81317, 81321,
81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311) provided to the enrollee on
February 26, 2021.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We
looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage
of the laboratory services have not been met. The laboratory services provided for the diagnosis of C79.10
(secondary malignant neoplasm of unspecified urinary organs) is not medically necessary. Therefore, we
decided that the Plan does not have to pay for the laboratory testing (CPT code(s): 81191, 81317, 81321,
81206, 81210, 81235, 81272, 81275, 81276, 81292, 81295, 81298, 81301, 81311) provided to the enrollee on
February 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (99601) provided June 1, 2021.
You asked the Plan to pay for the infusion services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed is not eligible for Medicare payment.
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 find that CPT code 99601 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, this code has a status of "I" and is invalid for Medicare payment. Based on this information, we
decided that Medicare rules for coverage of the infusion services have not been met. Therefore, we decided that
the Plan does not have to pay for infusion services (99601) provided June 1, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug test(s), presumptive, any number of drug classes,
any number of devices or procedures (CPT code 80307) provided to the enrollee on April 9, 2021.
You asked the Plan to pay for the drug testing. You say that the service was approved by the referring
physician. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must
follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug testing have not been met. Medicare will only pay for one presumptive
test result per patient, per date of service, regardless of the number of billing provider. Therefore, we decided
that the Plan does not have to pay for the drug test(s), presumptive, any number of drug classes, any number of
devices or procedures (CPT code 80307) provided to the enrollee on April 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on
January 21, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 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 out of network physician services provided to the
enrollee on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit (99336) rendered by the
out-of-network (OON) provider on June 9, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was 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 service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the domiciliary or rest home visit (99336) rendered by the out-of-network (OON)
provider on June 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extractions provided on July 20, 2021.
You asked the Plan to pay for the extractions. You say that you would like reconsideration because you have a
hereditary condition which made the extractions medically necessary. The Plan denied your request. The Plan
says there is no evidence that any of the medical conditions, treatments or medications were directly
responsible for the decay of your teeth and ultimately requiring dental extractions.
Medicare generally does not cover dental services. The Plan covers dental procedures for a beneficiary
admitted to a hospital for dental procedures only if hospitalization is necessary due to a preexisting medical
condition and prior approval is received from the Trustees.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Additionally, the record does not indicate that you were admitted to the hospital for the dental
procedures or that hospitalization was necessary due to a preexisting condition. Therefore, we decided that the
Plan does not have to pay for the extractions provided on July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (99601, 99602) provided July 8,
2021.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the codes billed are not eligible for Medicare payment.
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 find that CPT codes 99601, & 99602 are not supported in the medical record. Specifically, the billed codes
have a status of "I" per the National Physician Fee Schedule and are not eligible for Medicare payment. Based
on this information, we decided that Medicare rules for coverage of the home infusion services have not been
met. Therefore, we decided that the Plan does not have to pay for home infusion services (99601, 99602)
provided July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483, 80307) provided November 30, 2020.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan
denied your request. The Plan says the documentation does not support the billed services.
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 find that CPT code G0483, & 80307 is not supported in the medical record. Specifically, the place of
service on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office
setting). 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 (G0483, 80307) provided
November 30, 2020.