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

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you have burning foot pain and that your foot is misshapen.The Plan denied your request. The Plan says this item is not a covered benefit.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.  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-approvefoot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pay forsurgical services provided to the enrollee on June 27, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the services 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 the denied codes is:CPT 35351:Thromboendarterectomy, including patch graft, if performed; iliacCPT 35372:Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoralCPT 35302:Thromboendarterectomy, including patch graft, if performed, superficial femoral arteryCPT 35301:Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by neck incisionCPT 34812:Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, unilateral (List separately in addition to code for primary procedure) We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the enrollee underwent a single thromboendarterectomy of the right femoral system. Material wasremoved from contiguous vessels and closure of the vessels was completed with a single patch. Therefore, only one code should be billed. In this case, the main/largest vessel involved was the common femoral artery. Therefore, billing of a thromboendarterectomy to the common femoral artery is supported (35371). Separate billing of thromboendarterectomies to the contiguous superficial femoral and deep femoral arteries is not allowed (35372, 35302). Thromboendarterectomies of the iliac artery and carotid artery were not performed and are not billable (35351, 35301). The femoral artery was not opened for the purpose of inserting an endovascular prosthesis and is not billable (34812).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay forsurgical services provided to the enrollee on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee. You asked the Plan to pre-approve a power wheelchair and accessories. You say that The Plan denied your request. The Plan says that there is no documentation of the disrepair or the date the enrollee was given his current wheelchair. The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of equipment in no case can be less than five years. The documentation provided does not confirm the enrollee's current wheelchair is older than five years. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 20, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are
not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.
The tests at issue in this appeal, the lab services, were requested solely for screening purposes. Medicare does
not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay
for the lab services provided on December 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a motorized scooter.
You asked the Plan to pre-approve the scooter. You say that this is needed to move around. The Plan denied your request. The Plan says power operated vehicles with added capabilities that are inside of the home are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scooter. Our reviewer says that the requested scooter is not medically reasonable or necessary. Our physician reviewer found the documentation reveals the patient has a mobility deficit but the documentation is not clear that he is unable to perform MRADLS specifically due to this deficit. The document indicates the patient has caregiver assist that helps with all ADLs. The documentation indicates hypoxemia but there is no actual oxygen saturation with use of a manual wheelchair or walker. The documentation does not reveal upper extremity weakness on a physical exam. The documentation does not reveal details of the decreased shoulder range of motion that supports that the patient is limited with use of a manual wheelchair from this deficit. The documentation reveals the patient can safely operate a PMD but there are no details on the home assessment on the question whether there are obstacles or factors that will render the mobility device unusable in the patient's home. It is unclear why you require the Pride Maxima 4 wheeled power device that has a heavy duty drivetrain to go up a hill. 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 scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a motorized scooter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax.
You asked the Plan to pre-approve the CT scan. You say that the enrollee continues to have an elevated ESR coupled with neck, mid thorax and low back pain. The Plan denied your request. The Plan says there is no documentation of a recent abnormal chest x-ray.
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 CT scan. Our physician reviewer found that the enrollee is undergoing screening for a renal transplant. The enrollee reports ongoing mid thorax, low back and spine pain. He has a history of methicillin-susceptible Staphylococcus aureus osteomyelitis of the spine treated with extensive antibiotics. The enrollee underwent a magnetic imaging study of the spine noting no recurrent infection or other acute processes. A CT scan was ordered to rule out occult finding to explain elevated erythrocyte sedimentation rate and C-reactive protein values. The records do not include a history of specific complaints, a physical exam noting abnormal findings, or a differential diagnosis to support the requested study. There is no previous imaging of the chest noted in the documentation. Therefore the requested CT scan is not medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the thorax.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room Services (73030, 96374, 99284) provided November 3, 2019.
You asked the Plan to waive the copayment for the Emergency Room Services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost-sharing was 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 $100 copayment for Emergency Care. You have been asked to pay a $100 copayment for the Emergency Room Services. The Emergency Room Services falls within the Emergency Care 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 Emergency Room Services (73030, 96374, 99284) provided November 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. 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 Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was 95% on room air. There were no abnormal breath sounds. The enrollee does not have a tracheostomy tube, enteral feedings, complex wound care or other SNF level skilled nursing need. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 11, 2019.
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 Healthcare Common Procedure Coding System (HCPCS) G0483 remains not supported.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on November 11, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a knee arthroscopy with meniscectomy and possible chondroplasty.
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 that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has severe left knee pain with difficulty walking. Clinical exam findings are documented consistent with a medial meniscus tear and a full thickness chondral defect in the patellofemoral compartment. He has failed to improve with activity modification, medications, and cortisone injection. The requested left knee arthroscopic medial meniscectomy with chondroplasty is the standard of care for the enrollee's condition and would be considered medically reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve a knee arthroscopy with meniscectomy and possible chondroplasty.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular pathology procedure (81479) rendered on November 8, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider, without prior authorization.
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 has network providers available who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the molecular pathology procedure (81479) rendered on November 8, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide a Freestyle Libre Continuous Glucose Monitor (CGM) (A9278).
You asked the Plan to provide the CGM. You say that the CGM is medically necessary. The Plan denied your
request. The Plan says that rules for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they
are medically reasonable and necessary and replace a blood glucose monitor.
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 provide the CGM. Our reviewer says that the CGM
is medically necessary. Our physician reviewer found the record shows that the enrollee suffers from poor
dexterity which prevents use of a traditional glucometer. The Enrollee has a history of diabetes and use of a
glucometer is medically necessary to make necessary dietary changes.
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 CGM have been met. Therefore, we decided that the Plan has to provide a
Freestyle Libre Continuous Glucose Monitor (CGM) (A9278).
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 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 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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee was admitted to acute care with a broken right arm bone and needed surgery. Diagnoses include a right proximal humerus fracture status post total shoulder replacement 4/30/2020. Post-operative course has included medications, physical therapy, and rest. Now, the member is able to make needs known and is minimal/moderate assist for most mobility and activities of daily living per recent therapy notes. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the member is mostly moderate/minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a device to clean your CPAP machine.You asked the Plan to pre-approve the requested device. You say that you are worried that you are not cleaning your device well enough.The Plan denied your request. The Plan says the device is not used to care for a medical problem.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature.Therefore, we decided that the Plan does not have to pre-approve a device to clean your CPAP machine.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a chest x-ray (71046) provided January 5,
2020.
You asked the Plan to waive the copayment for the chest x-ray. You say that the copayment should be waived.
The Plan denied your request. The Plan says the correct copayment was applied for basic radiology in an
outpatient setting.
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 $25
copayment for Basic Radiology.
You have been asked to pay a $25 copayment for the chest x-ray. The chest x-ray falls within the Basic
Radiology 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 a chest x-ray (71046)
provided January 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve admission to a SNF. 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 the requested admission to a SNF.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission to a SNF. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted to acute care on 5/1/20 due to increasing falls over a two-week period. The enrollee was also noted to have a urinary tract infection. Now, medications include Macrobid. She has lower limb weakness objectively, and MRI evidence of multilevel cervical spondylosis. She has no displaced cervical spine fracture on CT. She is maximum/total assist for all care. She is non-toxic and afebrile. The enrollee is now maximum/total assist for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable and SNF 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 admission to a SNF have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on December 19, 2019.
You asked the Plan to waive the copayment for the MRI. You say that the implants were recalled so you were sent for an MRI. You say that you shouldn't have to pay because you were not at fault. The Plan denied your request. The Plan says the copayment applied correctly.
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 $100 copayment for each Medicare-covered MRI, CT or PET scan. You have been asked to pay a $100 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 the MRI provided on December 19, 2019.