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

We decided that the Plan does not have to pay forknee orthosis (L1833), bilateral ankle orthoses (L1971) and suspension sleeves (L2397) provided to the enrollee on February 22, 2020.You asked the Plan to pay forthe orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural censustract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay forknee orthosis (L1833), bilateral ankle orthoses (L1971) and suspension sleeves (L2397) provided to the enrollee on February 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy-duty power wheelchair.You asked the Plan to pre-approve a heavy-duty power wheelchair. You say that the item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that a POV is covered when specific criteria is 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 a heavy-duty power wheelchair. Our reviewer says that the item is not medically necessary. Our physician reviewer found in this case, you are not noted to have an inability to utilize a lesser device (lightweight manual wheelchair, standard manual wheelchair, or use of a walker). Therefore, this request 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 a heavy-duty power wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approve a heavy-duty power wheelchair.
Appeal type: SNF
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 a SNF is medically
necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for SNF admission.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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
enrollee does not meet criteria for SNF admission. Our physician reviewer found the enrollee was admitted to
acute care on 7/18/20 with left anterior cerebral artery (ACA) cerebral vascular accident (CVA). From a
nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. Regarding
rehabilitation services, the enrollee received physical therapy, speech therapy and occupational therapy in the
acute hospital. The enrollee was independent with bed mobility and at a supervision level with transfers and
gait to 300 feet with no assistive device. The enrollee required varying assist with activities of daily living. She
worked with speech therapy on cognitive-linguistic therapy. She had decreased safety awareness.
There are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The
enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet
severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility 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 waive the coinsurance forthe observation care from February 26,2020 through February 27, 2020.You asked the Plan to waive the coinsurance forthe observation care. You say that this should be covered because the emergency department told you they did not have any rooms to keep you overnight and transferred you to another emergency room.The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.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 records indicate that you were admitted at an observation level of care. An observation level of care is when the physician has determined that you require a period of observation to evaluate your condition. This cost sharing is a contractual obligation you agreed to when you enrolled with the Plan. Therefore, you will remain liablefor the $39 5copayment that applied for the outpatient hospital observation copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe observation care from February 26, 2020 through February 27, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT)
(78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that the services are necessary. The
Plan denied your request. The Plan says based on the documentations provided, coverage criteria has not been
met.
The Plan follows Medicare rules. Medicare rules say that myocardial perfusion studies are covered when
specific criteria is 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 myocardial perfusion imaging. Our
reviewer says that the services are not medically necessary. Our physician reviewer found based on the records
the enrollee has increased coronary risk but no cardiac symptoms, no ischemic electrocardiographic changes
and no ischemia on prior nuclear stress test less than 2 years ago. In this circumstance the documentation does
not support the medical necessity for repeat nuclear stress test and current guidelines do not consider the test
appropriate in this setting. Coverage criteria are not met since screening stress testing is not covered and has
not been shown to improve cardiac outcome.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that
the Plan does not have to pre-approve myocardial perfusion imaging, tomographic (SPECT) (78452).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy (S9500).
You asked the Plan to pre-approve home infusion therapy. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9500 is not supported in the medical record. Specifically, code S9500 has a status
indicator of "I" on the Physician Fee Schedule meaning that it is invalid for Medicare purposes. This code
describes services other than those provided by a skilled professional on an infusion drug administration
calendar day. This means that these services are not separately payable by Medicare. Based on this information,
we decided that Medicare rules for coverage of home infusion therapy have not been met. Therefore, we
decided that the Plan does not have to pre-approve home infusion therapy (S9500).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided in a nursing home on March 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe nursing home visit. You say that the rendering provider is a Hospitalist physician with the IPC group and depends upon the hospital staff to verify eligibility and to obtain the proper authorization for In-Network and Out-Network providers from the patient's insurance company.The Plan denied your request. The Plan says the enrollee was in a nursing home and was not receiving Medicare-covered skilled care. There is no reason noted that prior authorization was not requested prior to providing this care.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 has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The enrollee was not in a hospital and not in a Part A covered SNF stay. 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 forthe medical services provided in a nursing home on March 11, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveCT scan of the chest for the enrollee.You asked the Planto pre-approvethe scan. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested scan is not supported by evidence-basedguidelines, nor is there evidence that it is medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the enrollee's PSA has been stable at 0.14, and he has no chest complaints and no history of abnormality on prior chest CT or Axumin scans. The NCCN guidelines do not support the performance of surveillance chest CT in these clinical circumstances.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 scan have not been met.Therefore, we decided that the Plandoes not haveto pre-approveCT scan of the chest for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on November 21, 2019.You asked the Planto pay forthe presumptive and definitive drug testing. You say that the documentation supports that this testing was ordered and correctly performed.The Plandenied your request. The Plansaysthe order for this testing is not signed by the treating provider and there are no other records to verify the intent for this testing to be performed.The Plan must follow Medicare rules. Medicare rules say that lab testing may be covered only when ordered by the treating provider. The order does not have to be signed, but medical records must document the intent that the ordered testing be performed. The order form included in the file is not signed by the ordering physician referenced on the claim nor are there are records provided to confirm the intent to perform this testing.Therefore, we decided that the Plandoes not haveto pay forthe presumptive and definitive drug testing provided on November 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on March 11, 2020.You asked the Planto pay forthe testing. You say that this shoudl be paid for.The Plandenied your request. The PlansaysComprehensive GenomicProfile (CGP) testing (Guardant-360 and NEXT-Generation) requires use of CPT 81479.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 various denied CPTcodes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT 81479. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plandoes not haveto pay forComprehensive Genomic Profile (CGP) testing provided to the enrollee on March 11, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an x-ray of the knee received on February 26, 2020.
You asked the Plan to waive the copayment for the x-ray. You say that you feel like you should not to pay this copayment for the x-ray. The Plan denied your request. The Plan says you are responsible for applicable copayments.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Medicare-covered x-rays. You have been asked to pay a $45 copayment for the x-ray. The x-ray falls within the Medicare-covered x-rays benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an x-ray of the knee received on February 26, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery services received on March 20, 2020.You asked the Plan to waive the copayment forthe services. You say that there was no scalpel involved.The Plan denied your request. The Plan says you are responsible for the cost share applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300 copayment for outpatient surgery.You have been asked to pay a $300 copayment for the services. The services fall within the outpatient surgery benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for outpatient surgery services received on March 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy.
You asked the Plan to pre-approve the additional physical therapy. You say that you need additional home
therapy because you want to walk without assistance of any kind. The Plan denied your request. The Plan says
additional physical therapy is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 additional physical therapy. Our
reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration
of the enrollee's condition. Our physician reviewer found the requested additional therapy is not generally
accepted as specific and effective therapy for your condition. Your functional level does not reveal that you
require an ongoing skilled professional therapist to safely and effectively provide treatment. Services do not
need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The
documentation does not reveal that you are home bound and require home therapy. The requested services are
not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is
not required to establish, design and/or deliver a program to maintain your current condition or to prevent or
slow further deterioration.
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 additional physical therapy have not been met. Therefore, we decided that
the Plan does not have to pre-approve additional physical therapy.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of a biomechanical device (22853) provided on December 6, 2019.
You asked the Plan to pay for the insertion of a biomechanical device. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service 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, the CPT Code Manual definition of code 22853 is insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure). We asked our coder 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 insertion of a biomechanical device. Our reviewer says that CPT code 22853 does not meet criteria for reimbursement consideration. Our reviewer found the operative report did not document that an insertion of an interbody biomechanical device was performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of a biomechanical device have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of a biomechanical device (22853) provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the $25 copayment charged for podiatry services provided on January 6, 2020.You asked the Plan to waive this copayment. You say that you did not see the doctor, only the nurse practitioner and should not have to pay the copayment.The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.Medicare does not cover podiatry services. The Plan covers podiatry services with a $25 copayment. You were provided with treatment for an ingrown toenail. The copayment charged was done so correctly. Therefore, we decided that the Plan does not have to waive the $25 copayment charged for podiatry services provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on February 5, 2020.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that Guardant360 testing must be reported with one unit of CPT 81479 and the appropriate DEX Z-Code. We looked at the file and Medicare rules. The requested Guardant360 testing was billed with multiple CPT codes. Per the applicable article, this testing must be reported with CPT 81479 and the appropriate DEX Z-Code. 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 pay for the Guardant360 testing provided on February 5, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says there was no evidence provided that the enrollee's treatment needs could not be met at a less restrictive, ambulatory detox level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found it is not expected that this enrollee would improve in a reasonable period of time, as he did not have dangerousness to self or others, auditory or visual hallucinations, delusions and was not showing any behavioral issues. The enrollee was cooperative and compliant. He was not showing any active withdrawal symptoms requiring this level of care. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. The health plan's denial of inpatient psychiatric/detoxification services appears appropriate.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient mental health facility for the enrollee.