Persius/hicric huggingface dataset:
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. The Plan denied your request. The Plan says the enrollee does not require an interdisciplinary approach to rehabilitation 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 physician reviewer found that the enrollee was admitted to the acute care hospital for observation for a fall with rib fracture. She was discharged home. 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.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing provided on September 16, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. You say that you were unaware prior authorization was required and the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for drug testing provided on September 16, 2021, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy (PT) to be provided by an out-of-
network (OON) provider.
You asked the Plan to pre-approve physical therapy by an out-of-network provider. You say that the services
are necessary. The Plan denied your request. The Plan says these services are not covered when they are from
an out-of-network provider.
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
physical therapy (PT) to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).  You asked the Plan to pre-approve a pneumatic compression device. You say that the requested item is reasonable and necessary. The Plan denied your request. The Plan says the requested item is not a covered benefit.  The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.   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, this item is not a covered benefit of Medicare or the Plan. PCDs are not covered for preventions of venous thromboembolism, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0676).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo (Q5120).
You asked the Plan to pre-approve Ziextenzo. You say that the drug is medically necessary. The Plan denied
your request. The Plan says the drug/regimen is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer
drugs if they are medically accepted as safe and effective or appropriate for the particular use.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Ziextenzo. Our reviewer says that the
service is not medically necessary. Our physician reviewer found this drug is not FDA approved for your
diagnosis and its use is not supported by one of the major drug compendia or by clinical research that appears
in a CMS-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have
to pre-approve Ziextenzo (Q5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the acupuncture services. You say that you think you need acupuncture because you have seen a couple chiropractors who have not been able to fix your back issues. It is medically necessary because of the pain you feel every day and you have a hard time walking. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lower joint
extremity.
You asked the Plan to pre-approve the imaging. You say that this is medically necessary. The Plan denied your
request. The Plan says the notes do not show what type of knee problem is suspected.
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 imaging. Our reviewer says that the
requested imaging is not medically reasonable or necessary. Our physician reviewer found there are no reports
of x-rays of the symptomatic areas of the right lower extremity. There is no detailed physical exam, including
range of motion, pain, limitations of function, etc. Without this data, the medical necessity of the requested
exams has not been established.
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 imaging have not been met. Therefore, we decided that the Plan does not
have to pre-approve magnetic resonance imaging (MRI) of the lower joint extremity.
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 need rehab to improve mobility. The Plan denied your request. The Plan says you do not require intensive rehabilitation three hours a day.  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 physician reviewer found that you are living at home with difficulty with ambulation with new lower extremity prosthetic. Your medical problems are stable. You do not require treatment by multiple therapies in an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program.  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: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 17, 2021, through
May 19, 2021.
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that
the inpatient admission was not medically necessary per InterQual 2021 criteria.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found that the record showed that at the time of inpatient admission the admitting physician
reasonably expected that the enrollee's necessary hospital care (including earlier emergency department
and/or observation care) would span two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from May 17, 2021, through May 19, 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose
monitor (CGM) receiver and sensor.
You asked the Plan to pre-approve a FreeStyle Libre 2 therapeutic continuous glucose monitor (CGM) receiver
and sensor. You say that the items are medically necessary. The Plan denied your request. The Plan says the
member does not use insulin with at least three daily injections.
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 use insulin
with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a
FreeStyle Libre 2 therapeutic continuous glucose monitor (CGM) receiver and sensor have not been met.
Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre 2 therapeutic continuous
glucose monitor (CGM) receiver and sensor.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from July 24, 2020 to August 10, 2020.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was not submitted with the appropriate revenue codes.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the revenue code billed with Q5002 is not appropriate as it is not the same revenue code to match the date of service. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from July 24, 2020 to August 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics to treat flat feet and back pain.  You asked the Plan to pre-approve foot orthotics. You say that foot orthotics are medically necessary for flat feet and back pain. The Plan denied your request. The Plan says Medicare coverage criteria are not met.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. The medical records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics to treat flat feet and back pain.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Dexcom monitoring system (K0554) and supplies (K0553).  You asked the Plan to pre-approve a Dexcom monitoring system and supplies. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.    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 and use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a Dexcom monitoring system and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom monitoring system (K0554) and supplies (K0553).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.  You asked the Plan to pre-approve the compression stockings. You say that you need this item. The Plan denied your request. The Plan says this is not a covered item.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
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 is medically necessary. The
Plan denied your request. The Plan says the requested admission 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 the provided documentation indicates the enrollee has no complex nursing or
rehabilitation needs.
The reviewer found that while the enrollee has a need for rehabilitation therapy, there is no documentation of a
need for an intensive rehabilitation program. The reviewer found there is not a reasonable expectation that this
patient 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. Specifically, the file does not show the enrollee has
complex nursing or rehabilitation needs. 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 Gemtesa 75 mg tablet.  You asked the Plan to pre-approve Gemtesa. You say that the enrollee has tried alternative medications without success. You also say that the enrollee has done well on a sample of Gemtesa. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  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 Gemtesa 75 mg tablet.   Benefits for Gemtesa 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: 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 you do not have daily skilled nursing or therapy needs.  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 you are at a contact guard assist level for transfers and walking using a rolling walker. There are no records from occupational therapy with regard to your needs with activities of daily living. You do not require the services of a skilled professional nurse to provide medically necessary treatment. Although there are skilled therapy service needs, you do not require daily services on an inpatient basis.  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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visit services provided on September 24, 2021, to
October 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the home visit services. You say that you rely on the facility to obtain the
authorization. You say the services were medically necessary. The Plan denied your request. The Plan says no
prior authorization was obtained.
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 did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services. The
records provided for review do not show that the services at issue were urgent or emergent. Therefore, we
decided that the Plan does not have to pay for home visit services provided on September 24, 2021, to October
12, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 23, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says an appropriate modifier was not 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. In this case, we have confirmed that code 71045 is a column II code to column I code 77001. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on September 23, 2021.