Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.
You asked the Plan to provide coverage for additional routine transportation trips. You say that you were not aware that transportation trips would be limited per year. You also say you live alone, and you do not drive or have other assistance to get to and from appointments. The Plan denied your request. The Plan says additional trips would exceed your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy-duty bedside commode.
You asked the Plan to pre-approve an extra heavy-duty bedside commode. You say that that sitting on a regular
toilet is difficult and that you need this item. The Plan denied your request. The Plan says that you do not meet
the Medicare criteria for an extra heavy-duty bedside commode.
The Plan must follow Medicare rules. Medicare rules say that an extra wide/heavy duty commode chair is
covered for a beneficiary who weighs 300 pounds or more.
We looked at the file and Medicare rules. The file does not indicate you weigh more than 300 pounds. Based
on this information, we decided that Medicare rules for coverage of an extra heavy-duty bedside commode
have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy-duty
bedside commode.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve VascuTherm 5 (fluid circulating cold pad with pump)
(CPT code E0218).
You asked the Plan to pre-approve the item. You say that you will being having two (2) separate surgeries on
your shoulder and you need the VascuTherm 5 for healing. The Plan denied your request. The Plan says this is
not covered by Medicare or the Health Plan.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The rules say that a fluid
circulating cold pad with pump (E0218) will be denied as not reasonable and necessary. Therefore, we decided
that the Plan does not have to pre-approve VascuTherm 5 (fluid circulating cold pad with pump) (CPT code
E0218).
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical techniques requiring use of robotic surgical system (CPT code S2900), for the enrollee.
You asked the Plan to pay for the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not covered by Medicare or the Health Plan.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The status code for CPT code S2900 is "I". Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 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 pay for surgical techniques requiring use of robotic surgical system (CPT code S2900), for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve continuity of care (CPT code 99213) to be provided by an out-ofnetwork
provider.
You asked the Plan to pre-approve continuity of care. You say that the enrollee's needs would not be served
sufficiently at an office less acquainted with their history and care team. You state a sudden change in primary
care would lead to a "loss of care and de-compensation of the enrollee's condition" The Plan denied your
request. The Plan says that there are many comparable providers in-network with the Health Plan who could
provide appropriate care over time.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few
exceptions, enrollees must use contract providers for care.
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 continuity of care. Our physician
reviewer found a request for continuing care (extension) with the enrollee's current and long-time (since 2015)
out-of-network provider was made. Based on the provided documentation and statements, it is of the opinion of
the reviewer that it would place the enrollee at risk for decline in the enrollee's conditions if care is transferred
after having built relationships with the current team. Therefore, this request for an extension of care will be
considered 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 continuity of care have been met. Therefore, we decided that the Plan has to
pre-approve continuity of care (CPT code 99213) to be provided by an out-of-network provider.
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: 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 the complexity of your nursing, medical and rehabilitation needs do not require
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. 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.
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 pre-approve SMN1 genetic testing for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this testing is unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the enrollee.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has progressive right upper extremity and left lower extremity weakness. Prior SMA evaluation of SMN1 and SMN2 done 10/17/2013 was negative for mutations. Tier 2 genetic tests are unlikely to impact therapeutic decision-making, directly impact treatment, outcome and/or clinical management in the care of the enrollee and will be denied as not medically necessary. The review has determined that the enrollee does not meet the criteria for this testing. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve SMN1 genetic testing 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 you need acute rehabilitation to get back to your full mobility. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
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 your 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 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: 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 the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the records do not show a need for skilled therapy or nursing on a daily 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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and was placed on isolation. The enrollee had minimal symptoms and clear lungs. The enrollee received physical therapy, occupational therapy, and speech therapy. The enrollee was at a contact guard assist level with functional mobility, including gait to 100 feet. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs, but they are not required on a daily basis. The enrollee does not meet the 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 the 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested procedure is experimental/investigational.
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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the requested procedure is considered an experimental/investigational procedure. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy (97124).
You asked the Plan to pre-approve the massage therapy. You say that you would like reconsideration because
the requested massage therapy is medically necessary to treat the member's condition. The Plan denied your
request. The Plan says the documentation submitted does not include the member's functional goals of
treatment.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore,
we decided that the Plan does not have to pre-approve massage therapy (97124).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous glucose monitor for the enrollee.
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that insulin doses are not adjusted daily based on blood glucose readings.
The Plan must follow Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the requested services are medically reasonable and necessary. Our physician reviewer found the blood glucose data that the enrollee is being asked to provide will be used by the enrollee and the provider to adjust the insulin plan. The enrollee should be viewed as meeting the coverage criteria. 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 monitor have been met. Therefore, we decided that the Plan has to pre-approve a continuous glucose monitor for the enrollee.
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 manual wheelchair with tilt in space, adjustable foot plates, and brake extension.
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 a manual wheelchair is 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 requested manual wheelchair with tilt in space, adjustable foot plates, and brake extension exceeds the enrollee's needs. The durable medical equipment (DME) consultation indicates that the tilt in space is not indicated due to worsening of his gastric symptoms in the tilt position. He does not require brake extensions as his caregivers can lock his wheelchair without these. He is dependent on staff for wheelchair propulsion and activities of daily living. The requested manual wheelchair is 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 a manual wheelchair with tilt in space, adjustable foot plates, and brake extension
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from September 6,
2020 to September 17, 2020.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the submitted records do not support the billing of DRG 268 and diagnosis code K66.1.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.
In this case, you billed the inpatient services provided with DRG 268 (aortic and heart assist procedures except
pulsation balloon w mcc) and secondary diagnosis K66.1 (hemoperitoneum). 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 these services. Our reviewer says that the submitted records do not support the
billing of DRG 268 and diagnosis code K66.1. Our physician reviewer found physician documentation of
hemoperitoneum could not be found within the medical record. The preop and postop diagnoses state, "Large
abdominal aortic aneurysm with retroperitoneal hemorrhage and impending rupture aneurysm." Cardiology
consultant documented, "There is signs of some retroperitoneal bleed." When utilizing the ICD-10-CM
Alphabetic Index, "hemorrhage retroperitoneal" results in code R58, (Hemorrhage, not elsewhere classified).
Code assignment is based on clear and consistent physician documentation along with adhering to code
assignment rules. All diagnoses should be supported by provider documentation. The records do not support
the billed DRG and diagnosis code.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital services rendered from September 6, 2020 to September 17, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for Skilled Nursing Facility (SNF) services billed with Patient Driven Payment Model (PDPM) code GAKE1x20 and provided on August 1, 2020, through August 21, 2020.
You asked the Plan to pay for the SNF services billed with PDPM GAKE1x20. You say that you would like reconsideration because the medical documentation supports the PDPM. The Plan denied your request. The Plan says that the documentation provided does not support coding of all Section GG payment items which results in a reduction of the PT/OT and nursing components of the PDPM score.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the record indicates that the Plan reviewed medical records to determine that the PDPM coding is not supported. The Plan has failed to forward medical records. Without the clinical information that was reviewed by the Plan, we are unable to determine if coding criteria have been met. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for Skilled Nursing Facility (SNF) services billed with Patient Driven Payment Model (PDPM) code GAKE1x20 and provided on August 1, 2020, through August 21, 2020.
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 seat lift.
You asked the Plan to pre-approve a seat lift. You say that you are unable to walk any distance and unable to
raise yourself from a regular chair or armchair in your home. The Plan denied your request. The Plan says a
chair that sits over the lift mechanism is not a Medicare covered benefit.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we
decided that Medicare rules for coverage of a seat lift have not been met. The correct code for recliner is A9270
rather than E1399. The denial for a chair that sits over the lift mechanism (correctly coded under A9270) is
upheld as it is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to preapprove
a seat lift
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Praluent injection 150mg/ml for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Praluent injection 150mg/ml for the enrollee