Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 2,
2021.
You asked the Plan to pay for procedure code 62320. You say that these services were billed correctly so they
should be paid. The Plan denied your request. The Plan says the medical records do not support payment for
this service.
The Plan must follow Medicare rules. Medicare rules say that in order for code 62320 to be covered, certain
documentation requirements must be met. The documentation must include a procedure report that clearly
documents the indications and the medical necessity for the blocks along with the pre and post percent pain
relief achieved immediately post-injection.
The medical records in this case do not meet Medicare's documentation requirements. Specifically, the record
does not include a notation of the percent of pain relief achieved either before or after the injection. Therefore, we decided that the Plan does not have to pay for procedure code 62320 billed for date of service August 2,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services provided on August 20, 2021, by an out-of-
network (OON) provider.
You asked the Plan to pay for the medical services. You say that these services should be paid, and you have
provided medical records to support payment. The Plan denied your request. The Plan says unauthorized, non-
plan care is not covered. The Plan also states that they contacted the member's primary care physician, and
they confirmed that they did not refer this patient to this out-of-network facility.
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 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 medical services provided on August 20, 2021, by
an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda.  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. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 primary peritoneal cancer diagnosed in 2009. She is BRCA-negative with several prior lines of chemotherapy. Keytruda is not approved by the Food and Drug Administration (FDA) for treatment of peritoneal cancer. Off-label use is not supported by major drug compendia for off-label use or the medical literature. The enrollee does not carry any molecular markers that would support use based on next generation sequence. The service is 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 Keytruda.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (82306).
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for the laboratory services (82306).
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 9 additional home nursing visits.  You asked the Plan to pre-approve 9 additional home nursing visits. You say that denying access to skilled services puts her at high risk for visits to the emergency room and hospitalizations secondary to cardiac complications. You say that access to these services will help improve her health outcomes and allow her to manage the recommended treatment plan. The Plan denied your request. The Plan says the records do not support the need for additional skilled nursing visits.  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 9 additional home nursing visits. Our reviewer says that home health skilled nursing services are not medically necessary or reasonable. Our physician reviewer found that the enrollee has an available caregiver and does not have documented home health skilled nursing needs.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 9 additional home nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 9 additional home nursing visits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is medically necessary to improve the enrollee's quality of life. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records do not show they have been evaluated by multiple specialties for their condition. The Plan states the enrollee has not had maximal medical management and there is no adequate documentation of any form of neurosurgical evaluation that indicate that the enrollee is not a surgical candidate.  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 service. Our physician reviewer found the enrollee has not exhausted all attempts at care for back pain. A surgery consultation 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the percutaneous implantation of neurostimulator electrode array, epidural (CPT code 63650), for the enrollee.
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 appears to be still somewhat unstable and should require additional short-term acute care hospital services that can safely be received at the current facility. There are no services at LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer may be considered when treatment has completed and the enrollee is more stable.    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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that it does not appear the patient is in need of therapy at the level of
intensity that requires a skilled nursing facility at this time. 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 reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre 2 therapeutic CGM reader and sensor (CPT code(s): K0553 and K0554), for the enrollee.
You asked the Plan to pre-approve the CGM and supplies. You say that the CGM and supplies is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The enrollee's records do not show they receive at least three (3) insulin injections per day, and they are not on a continuous insulin infusion pump. Based on this information, we decided that Medicare rules for coverage of the CGM and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre 2 therapeutic CGM reader and sensor (CPT code(s): K0553 and K0554), for the enrollee.
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 you do not require treatment by multiple therapies, including either physical therapy
or occupational therapy, and an intensive rehabilitation therapy program. There is not a reasonable expectation
that you 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dupixent 300/2ML injection, for the enrollee.  You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your request. The Plan says Dupixent injection 300/2ML to be administered at home is not Medicare covered under the Part A or B benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent 300/2ML injection, for the enrollee.   Benefits for the injection 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Dexcom G6 transmitter (CPT code K0553).  You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.      We looked at the file and Medicare rules. The documentation does not show you are currently treated with insulin and that you are injecting insulin three or more times per day or is using a Medicare-covered continuous subcutaneous insulin infusion (CSII) pump. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does not have to pre-approve Dexcom G6 transmitter (CPT code K0553).
Appeal type: Other
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve RomTech portable connect adaptive rehabilitation device and a remote treatment function device.  You asked the Plan to pre-approve the items. You say that the items are necessary. The Plan denied your request. The Plan says the items are not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The requested DME is an exercise bicycle equipment and therefore a non-covered item and a non-medical item in nature. Therefore, we decided that the Plan does not have to pre-approve RomTech portable connect adaptive rehabilitation device and a remote treatment function device.
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 transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. All services that would be provided in the LTACH are being provided in the current acute setting which is already approved. The enrollee can remain in the current acute care location until such time no further acute level care is needed.
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 appears to be somewhat unstable and has not had a successful weaning attempt. The enrollee requires short-term additional acute care services that can be safely administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility.
Transfer to the LTACH is not medically necessary as it would not be clinically advantageous at this time. Transfer may be considered when treatment has completed and the enrollee is more stable. 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: 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 you just had knee replacement surgery and the Plan is just sending you to a nursing facility. You said that you need acute rehab instead. The Plan denied your request. The Plan says you do not meet criteria for acute inpatient rehabilitation.
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 you are medically stable and do not physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. An uncomplicated post-surgery patient at the current functional status, needs routine PT and OT and does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Our doctor says that IRF admission is not medically necessary based on lack of medical complexity, and lack of nursing needs. While you may benefit from physical or occupational therapy, your rehab 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: 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 needs rehabilitation. The Plan denied your request. The Plan says the enrollee does not appear to require the intensive rehabilitation of an IRF. The enrollee's needs can be met at a lower level of care.  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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for COVID-19 testing received on September 15, 2021.
You asked the Plan to pay for the services. You say that you were carefully following travel guidelines. The
Plan denied your request. The Plan says this was due to voluntary travel.
The Plan must follow Medicare rules. The rules say a plan must disclose to its enrollees in clear, accurate terms
all cost sharing information (such as copayments, deductibles and coinsurance).
The plan does not cover these tests based on travel-related requirements. 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 COVID-19 testing received on September 15, 2021