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

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).

You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that please see attached for documentation from the enrollee's healthcare team in support of medical necessity of the prescribed Flexitouch PCD for the treatment of her lymphedema. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 14, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 14, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 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 inpatient psychiatric care from
November 14, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient
mental health treatment beyond the date in question of November 14, 2021, forward. Our physician reviewer
found the enrollee did not require inpatient mental health treatment beyond November 14, 2021, as he was not
a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear
that active treatment was taking place beyond the date in question. It did not appear that the services for the
dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for
the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from November 14, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 14,
2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on May 19, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the record shows that only 18 drug classes were tested. 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 pay for the definitive drug testing rendered on May 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visits and additional supplies and materials provided on May 27, 2021, and June 10, 2021.

You asked the Plan to pay for the office visits and additional supplies and materials. You say that the testing provided is to ensure the continued safety of the patients and staff in the facility. You say that reimbursement should be allowed as it was medically necessary in providing close contact care to patient. The Plan denied your request. The Plan says bundled services are not eligible for separate reimbursement.

Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare also only covers manual manipulation of the spine to correct a subluxation. However, the Plan offers a chiropractic benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

Though the Plan offers a chiropractic benefit in excess of Medicare coverage, the requested items or services are not covered. The Plan already covered 30 chiropractic visits which exhausted your benefit. The additional supplies and materials are not covered because bundled services are not eligible for separate reimbursement. Therefore, we decided that the Plan does not have to pay for the office visits and additional supplies and materials provided on May 27, 2021, and June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care (99232) provided April 7, 2021.
You asked the Plan to pay for the hospital care. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says medical records are still needed to support CPT code 99232 on date of service April 7, 2021.
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 99232 is subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: an expanded problem focused interval history, an expanded problem focused examination, medical decision making of moderate complexity We find that CPT code 99232 is not supported in the medical record. Specifically, the provider has failed to provide information to support services were for April 7, 2021. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care (99232) provided April 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that the requested admission is not medically reasonable or necessary Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for skilled nursing facility (SNF) care provided from May 06, 2021, to May 28, 2021.
You asked the Plan to pay for SNF care. You say that this treatment is supported in the records. The Plan denied your request. The Plan says that this was not billed with a valid Patient-Driven Payment Model (PDPM) code.
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. We find that the Plan did not submit a compelling denial rationale in this case. The claim was denied due to the billed PDPM code being invalid. However, the billed PDPM, FBTD1, is a valid PDPM code. The Plan has not made any argument that any of the specific digits of the billed HIPPS code are incorrect or not supported. The initial denial indicates that the billed code does not match the authorized code; however, based on how the code is calculated, it is not reasonable to expect or require that the code requested for authorization be the code that is billed. The code billed must correspond to the enrollee's actual condition and the services actually rendered during the statement period of the claim. It would therefore be expected that the billed code would differ from a code that was estimated prior to the services being rendered. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care provided from May 06, 2021, to May 28, 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance angiography, head (70544).
You asked the Plan to pre-approve the MRA. You say that the medical records provided will show proof of
medical necessity. The Plan denied your request. The Plan says the medical records do not support that the
requested MRA is medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRA. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the enrollee has migraines and trigeminal neuralgia described as headaches across forehead and
eye to cheek. She has failed medications and was offered Botox by neurologist but refused. An increase in
memory loss was also noted. An MRI and MRA of the brain were requested and only the MRI was approved.
An MRI would be sufficient to evaluate this enrollee's condition. There was insufficient support made in the
provided documentation for the MRA at this time. Therefore, the MRA will be considered 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 MRA have not been met. Therefore, we decided that the Plan does not have
to pre-approve magnetic resonance angiography, head (70544).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gammaked infusion (J1561) every 3 weeks.
You asked the Plan to pre-approve Gammaked infusion. You say that this drug should be covered for the enrollee's diagnosis. The Plan denied your request. The Plan says the requested drug is not medically reasonable or necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for 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 Gammaked infusion. Our reviewer says that Gammaked infusion is not medically necessary. Our physician reviewer found the record indicates that the enrollee has a diagnosis of seronegative myasthenia gravis, not in acute crisis. The reviewer found that the Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The reviewer found that Medicare approved drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. Therefore, the reviewer found that the request for Gammaked infusion is not medically reasonable or 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 Gammaked infusion have not been met. Specifically, the file shows that the requested drug is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Gammaked infusion (J1561) every 3 weeks.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve joint aspiration.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral knee osteoarthritis. He is taking Gabapentin, Duloxetine, Tramadol, BuTrans, Naproxen and Tizanidine for pain. He has had trials of physical therapy. He had prior intra-articular steroid injections of his knees that produced greater than 50 percent pain relief for three months. The records support that the requested services are reasonable and medically necessary at this time. 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 been met. Therefore, we decided that the Plan has to pre-approve joint aspiration.
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 definitive drug testing provided from April 13, 2021, to June 22, 2021.
You asked the Plan to pay for the testing services. You say that the testing is medically necessary for monitoring. The Plan denied your request. The Plan says the documentation does not indicate how the test results would impact treatment.
The Plan must follow Medicare rules. Medicare rules say that urine drug testing may be reasonable based on specific indications documented in the medical record. In this case, the CPT Code Manual definition of code G0481 is definitive drug testing of 8-14 drug classes. We find that CPT code G0481 is not supported in the medical record. Specifically, the records provided do not show that the testing at issue was ordered based on medication side effects or inefficacy, suspicious behaviors, or other clinician documented change in affect or behavioral pattern. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that the Plan does not have to pay for the definitive drug testing provided from April 13, 2021, to June 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered on May 18, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code G0483 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 G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the records show that only 18 drug classes were tested. 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 pay for the definitive drug testing rendered on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 7, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the claim processed correctly.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the Plan processed the claim correctly. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on July 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you're running out of supplies and this has been covered in the past. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the RFA services. You say that the enrollee has tried home exercise and
medication but continues to experience pain with daily activities. You say that the enrollee's pain scale is at a 6.
You say that the enrollee did get 60% relief from a 2nd facet block injection but is now in a lot of pain. The
Plan denied your request. The Plan says the clinical documentation provided does not show that the guidelines
for coverage have been met.
The Plan follows Medicare rules. Medicare rules say that therapeutic facet joint procedures are considered medically reasonable and necessary for patients who have had two diagnostic facet joint procedures that have each provided a consistent minimum of 80% relief of primary pain. 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 RFA services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has chronic low back pain. She has been treated with medical therapy and a home exercise program. The documentation indicates that she had the first set of medial branch blocks (MBBs) on August 25, 2021, and the second set on September 20, 2021. She reported 60% pain relief from the second MBB. 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 RFA services have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 8, 2021,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 8, 2021, forward. You say that
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue
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 inpatient psychiatric care from
November 8, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient
mental health treatment beyond the date in question of November 8, 2021, forward. Our physician reviewer
found the enrollee did not require inpatient mental health treatment beyond November 8, 2021, as he was not a
danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear
that active treatment was taking place beyond the date in question. It did not appear that the services for the
dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for
the purpose of diagnosis.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric care from November 8, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 8,
2021, forward.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health counseling and therapy provided from August 31, 2020, to December 30, 2020.
You asked the Plan to pay for the behavioral health counseling and therapy. You say that you and your provider were not aware that the facility was out-of-network. The Plan denied your request. The Plan says the provider is not a Medicare-qualified mental health care professional.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered Medicare items or services from either Medicare or a Medicare beneficiary, a provider or supplier must be enrolled in the Medicare program. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the behavioral health counseling and therapy have not been met. This provider is an addiction counselor and not eligible to enroll in Medicare, therefore this provider is not payable. Therefore, we decided that the Plan does not have to pay for the behavioral health counseling and therapy provided from August 31, 2020, to December 30, 2020