Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Partially Favorable

We decided that the Plan has to pre-approve additional speech therapy visits 2 times a week for 4 weeks. We
decided that the Plan does not have to pre-approve additional speech therapy 2 times a week for 4 weeks and 2
times a week for 5 weeks.

You asked the Plan to pre-approve additional speech therapy visits. You say that additional speech therapy is
medically necessary. The Plan says that additional speech therapy is not medically necessary.

We decided that the Plan has to pre-approve additional speech therapy 2 times a week for 4 weeks.

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 speech therapy visits. Our
physician reviewer found that additional speech therapy visits 2 times a week for 4 weeks are reasonable and
medically necessary. The documentation supports the need for some of the requested additional speech therapy
visits.

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 speech therapy visits 2 times a week for 4 weeks been met.
Therefore, we decided that the Plan has to pre-approve additional speech therapy visits 2 times a week for 4
weeks.

We also decided that the Plan does not have to pre-approve additional speech therapy 2 times a week for
4 weeks and 2 times a week for 5 weeks.

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 speech therapy 2 times a
week for 4 weeks and 2 times a week for 5 weeks. Our reviewer says that the additional speech therapy visits
are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our
physician reviewer found that the frequency of the speech therapy is excessive and 2 times a week for 4 weeks
is acceptable for his deficits.

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 speech therapy 2 times a week for 4 weeks and 2 times a week for 5
weeks have not been met. Therefore, we decided that the Plan does not have to pre-approve additional speech
therapy 2 times a week for 4 weeks and 2 times a week for 5 weeks.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99204) and the consultation (CPT code 99244) to be provided by an out-of-network provider.

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 service is available in-network.

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 office visit (CPT code 99204) and the consultation (CPT code 99244) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injections.
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. Medicare rules say that therapeutic facet joint injections 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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has had two previous
injections in the 12 month period preceding the request. The record indicates greater than 60 percent
improvement for at least three months. The records do not indicate why the enrollee is not a candidate for
radiofrequency ablation. The criteria for coverage of the therapeutic facet joint injections are not met and 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 therapeutic facet joint injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).

You asked the Plan to pre-approve a CGM. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria.

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 perform blood glucose testing at least four times per day, does not use insulin with at least three daily injections, does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results, and has not had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to provide a positron emission tomography (PET) with concurrently
acquired computed tomography (CT).
You asked the Plan to provide a PET with CT for attenuation correction and anatomical localization imaging;
whole body (78816). You say that the enrollee needs the PET CT to determine a true diagnosis. The Plan
denied your request. The Plan says the enrollee is not receiving active treatment.
The Plan must follow Medicare rules. Medicare rules say that PET 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 provide a PET with CT for attenuation correction
and anatomical localization imaging; whole body (78816). Our reviewer says that PET CT scan is not
medically reasonable and necessary. Our physician reviewer found the record provided does not support that a
diagnosis of multiple myeloma has been made has been made. The elements of the coverage criteria for an
initial scan are not satisfied. The enrollee had a negative PET scan in October 2020. The enrollee is not
receiving active treatment. The elements of the coverage criteria for subsequent scans is not satisfied.
The requested service cannot be 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 a PET with CT for attenuation correction and anatomical localization imaging; whole body (78816) have not been met.
Therefore, we decided that the Plan does not have to provide a positron emission tomography (PET) with concurrently acquired computed tomography (CT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an extraction (D7210), and non-intravenous conscious sedation (D9248) provided on March 31, 2021.

You asked the Plan to pay for an extraction, and non-intravenous conscious sedation. You say that the services were medically necessary, and you were told to see an oral surgeon. The Plan denied your request. The Plan says you are not covered for these services when seen by an out-of-network provider.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of an extraction, and non-intravenous conscious sedation have not been met. Specifically, services were provided by an out-of-network provider without prior authorization. The Plan has contracted providers
available to provide these services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an extraction (D7210), and non-intravenous conscious sedation (D9248) provided on March 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Coflex device.
You asked the Plan to pre-approve a Coflex device. You say that the requested Coflex device is medically necessary. The Plan denied your request. The Plan says the requested Coflex device is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Coflex device. Our reviewer says that the requested Coflex device is not medically necessary. Our physician reviewer found the Coflex device is experimental. More research is needed to show safety and efficacy. The requested Coflex device is not 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 a Coflex device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Coflex device
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0482) provided on March 22, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you were not aware of the requirement to obtain a prior authorization for services. You also say you conducted the test ordered in good faith upon the provider's certification that the services were medically necessary. The Plan denied your request. The Plan says services should be received from network providers who are listed in the provider directory, except when urgent or an emergency.
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. The records provided for review do not show that the services at issue were urgent or emergent. 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 drug testing (80307, G0482) provided on March 22, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optune Lua tumor treatment field therapy
(TTFT)(E0466).
You asked the Plan to pre-approve the TTFT. You say that the TTFT should be covered. The Plan denied your
request. The Plan says the enrollee does not meet coverage criteria.
The Plan must follow Medicare rules. Medicare rules say that Tumor treatment field therapy (E0766) is
covered for the treatment of newly diagnosed Glioblastoma Multiforme. The enrollee does not meet this
criteria.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the TTFT have not been met. Therefore, we decided that the Plan does not have to pre-approve an
Optune Lua tumor treatment field therapy (TTFT)(E0466).
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 meets criteria for IRF and needs this
higher level of care. The Plan denied your request. The Plan says based on Medicare guidelines and the
information the Plan has about the enrollee's condition, the enrollee does not meet IRF requirements.
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 that 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. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation
does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve twenty (20) sessions for the special pressure chamber that increases oxygen in the blood (HBOT) (CPT code(s): 99183 and G0277), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee's doctor has debrided the wound and now would like to use hyperbaric treatment to increase the speed of healing. The Plan denied your request. The Plan says the enrollee does not qualify for this treatment as they have only had two (2) weeks of standard treatment and the enrollee's blood sugar is not controlled.
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 review indicates that the enrollee has a diabetic foot wound that has been present two times a week. The provider has debrided the wound and now would like to use hyperbaric treatment to increase the speed of healing. The enrollee has uncontrolled diabetes as evidenced by HgbA1C of 10.2. Additionally, the enrollee's wound appears to be making slow improvement with standard wound care. The review has determined that the medical records provided do not meet the requirements listed in the NCD for Medicare 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve twenty (20) sessions for the special pressure chamber that increases oxygen in the blood (HBOT) (CPT code(s): 99183 and G0277), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Heplisav-B injection.
You asked the Plan to pre-approve the requested service. You say that the vaccine is needed for preventative Hepatitis B. The Plan denied your request. The Plan says this service is only covered under the medical benefit if the enrollee has been exposed to the virus.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the requested service. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the requested service. Therefore, we decided that the Plan does not have to pre-approve a Heplisav-B injection.
Benefits for the requested service may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided from March 1, 2021, to 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 a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for these services. 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 services (99072) provided from March 1, 2021, to March 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the respiratory and Coronavirus molecular pathogen panel
provided on April 16, 2021.
You asked the Plan to pay for the respiratory and Coronavirus molecular pathogen. You say that you would
like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are
not a covered benefit.
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 87496, 87498, 87541, 87640, 87798, and 87532 are not supported in the medical
record. Specifically, the submitted documentation indicates that more than five targets were performed. There
is a more appropriate code to describe the services provided. In addition, multiplex polymerase chain reaction
respiratory viral panels of 6 or more pathogens are non-covered. Based on this information, we decided that
Medicare rules for coverage of the respiratory and Coronavirus molecular pathogen have not been met.
Therefore, we decided that the Plan does not have to pay for the respiratory and Coronavirus molecular
pathogen panel provided on April 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99072) provided from February 5, 2021, to February 20, 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 a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Code 99072 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for these services. 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 services (99072) provided from February 5, 2021, to February 20, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a polysomnography.

You asked the Plan to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810). You say that the enrollee has requested a repeat sleep study due to a different pressure sensation from her CPAP machine. The Plan denied your request. The Plan says there is no documentation that the CPAP machine is no longer working, or the enrollee has had return of symptoms of OSA.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810). Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the CPAP machine is no longer working nor is there any indication that the member has had a return of the symptoms for obstructive sleep apnea to indicate ineffectiveness of current CPAP machine. There is no daytime sleepiness etc. The member requested a repeat sleep study due to a different pressure sensation from her CPAP machine. Medicare states that a repeat or follow-up polysomnography can be covered as medically necessary in the setting of substantial weight changes or when symptoms return despite a good prior response to treatment with CPAP. The review has determined that the the requested polysomnography 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 polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist (95810) have not been met. Therefore, we decided that the Plan does not have to pre-approve a polysomnography.