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

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 reviewer says that the 
requested wheelchair is not medically reasonable or necessary. Our physician reviewer found there is no 
qualifying diagnosis for a K0861 group 3 power wheelchair. There is no ventilator, mobility limitation  due to a 
neurological condition, myopathy or a congenital skeletal deformity according to the 8/31/21 physician signed 
order. Furthermore, the documentation is not clear on the enrollee's current power wheelchair, and why the 
enrollee is unable to use this device for MRADLs in the home. 
 
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 a power wheelchair and accessories for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that you need skilled rehabilitation and are currently 
unsafe to discharge to go home. The Plan denied your request. The Plan says your records do not show that you 
require daily skilled services that can only be provided on an inpatient basis. The Plan states the services you 
require, such as additional therapy services, can safely be received at a different setting, for example, home 
with home health, in residential care, or home with close follow-up with your doctor. The Plan states you may 
discuss the best option with your provider. 
 
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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you did not have any parental medication, 
complex wound care or nutrition given via a feeding tube. You were medically stable without any acute 
exacerbations of chronic medical problems. Your physical function was at or near your baseline and she could 
have received further services at a lower level of care. Admission to the nursing facility at a skilled level of 
care for inpatient skilled services was 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation device (TENS) 
pneumatic compression vasopneumatic device and multivitamin injections. 
 
You asked the Plan to pay for the TENS device, pneumatic compression device and injections. You say that the 
medical records provided support the necessity of the services in dispute. The Plan denied your request. The 
Plan says vitamin injections are not covered by Medicare. The records do not support the necessity of the 
TENS device including supplies and Pneumatic compression vasopneumatic devices can be covered only for 
the treatment of chronic venous insufficiency with venous stasis ulcers, and refractory lymphedema. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the TENS device, pneumatic compression 
device and injections. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the services billed for/provided as they 
related to the applicable NCD's, were not performed for conditions for which the NCD supports the 
use/administration of these technologist. The enrollee's diagnosis (diagnoses) are not ones for which the NCD 
otherwise supports provision of this service. The technologies/used as part of the treatment provided are not 
readily supported as a standard of practice or care. There is an absence of credible literature to support the use 
of the form of treatment provided. Nor is it supported or even suggested for use in any practice guidelines. 
Consequently, these services would not have been 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 TENS device, pneumatic compression device and injections have not been 
met. Therefore, we decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation 
device (TENS) pneumatic compression vasopneumatic device and multivitamin injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says your needs are not skilled in nature.
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 SNF services. Our physician reviewer found that from a nursing perspective, you received oral medications, had stable vital signs, and his lungs were clear. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, you were at a standby assist level with functional mobility. You required varying assist with activities of daily living. Although there are identifiable skilled therapy service needs, you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee is a fall risk and needs to regain strength. The Plan denied your request. The Plan says the enrollee does not require daily skilled service on an inpatient basis.
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 SNF services. Our physician reviewer found that the enrollee was admitted to an acute care hospital with pneumonia due to an infection with the coronavirus. The most recent therapy documentation indicates she is able to ambulate up household distances with contact guard assistance and a walker. She is able to transfer and accomplish bed mobility without hands-on assistance. She is medically stable and does not have any complex daily wound care, parental medications or required care for a feeding tube. She does not require skilled nursing and/or skilled therapy services on a daily basis. Therefore, an admission to a SNF for inpatient skilled services is 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
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 that there is no documentation that you require the intensive rehabilitation therapy 
program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be 
appropriate for you in this case. 
 
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: Drugs
Decision: Favorable

We decided that the Plan has to pay for the drug testing (G0483) provided on May 20, 2021.
You asked the Plan to pay for the drug testing services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the documentation does not support that 22 drug classes were tested.
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 drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is supported in the record. Specifically, the record clearly indicates that more than 22 drug classes were tested. Based on this information, we decided that Medicare rules for coverage of the drug testing services have been met. Therefore, we decided that the Plan has to pay for the drug testing (G0483) provided on May 20, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on April 20, 2021, by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that prior to receiving these services you contacted the Plan and were given the name of this treating
provider. The Plan denied your request. The Plan says services performed by an OON provider are not covered
because your healthcare plan does not have OON benefits. The Plan also says that you were given the names of
two in-network providers, but the provider you were treated by was not one of these.
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.
Though the Plan offers a dental benefit in excess of Medicare coverage, you are responsible for 100% of the
cost for dental services rendered by an OON provider. Therefore, we decided that the Plan does not have to pay
for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on
April 20, 2021, by an OON provider
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 12, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their 
denial. The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that the laboratory services are not supported in the medical record. Specifically, If a laboratory 
procedure produces multiple reportable test results, only a single code shall be reported for the procedure. If 
there is no code that describes the procedure, the laboratory shall report a miscellaneous or unlisted procedure 
code with a single unit of service. Review of the file does not support that only one single code was billed for 
the services rendered. This means that the services were billed incorrectly. 
 
Based on this information, we decided that Medicare rules for coverage of the laboratory services have not 
been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 
12, 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 is not medically necessary.
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 there is no need for physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. Based upon your current level of function, you do not require an intensive, complex, multidisciplinary approach to daily therapy. Documentation does not support the need for a therapy program consisting of at least 3 hours of therapy per day at least 5 days per week with an interdisciplinary approach to rehabilitation care. There are no documented skilled nursing needs. While you may benefit from physical therapy and occupational therapy, your rehabilitation needs can be safely met in an alternate and lower intensity 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 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 the home ventilator (CPT code E0466), for the enrollee. 
 
You asked the Plan to pre-approve the home ventilator. You say that this is to be used for the treatment of 
chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the request for a 
home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be 
delivered by bilevel positive airway pressure (BiPAP) is not covered. 
 
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 physician 
reviewer found a home ventilator is not medically necessary. This patient has severe COPD, with mild carbon 
dioxide (CO2) retention on an arterial blood gas done under unknown circumstances. The enrollee may benefit 
from BiPAP support during sleep. But Medicare does not cover a home ventilator when used as BiPAP; certain 
BiPAP devices can provide the AVAPS mode of support, at less cost to the enrollee. The denial is upheld.  
 
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 (CPT code E0466), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies (A6212, A6196) provided on February 12, 2021.
You asked the Plan to pay for the wound care supplies. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says these claims have denied correctly.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home. Records show that the wound care supplies were used in a SNF or hospital. Therefore, we decided that the Plan does not have to pay for the wound care supplies (A6212, A6196) provided on February 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee continues to receive acute care services and these have not been denied.
The medical record does not indicate that the enrollee requires services that she is not currently receiving but
that would be available at the LTACH facility.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is lack of literature to support improved outcomes for this procedure.
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 the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure (22899).
You asked the Plan to pre-approve the Intracept procedure. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is experimental.
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 the Intracept procedure. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental, and more research is needed to show safety and efficacy for the enrollee's 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 the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure (22899).