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

We decided that the Plan does not have to pre-approvea Group 3 power wheelchair (PWC) with multiple power options.You asked the Plan to pre-approvethese 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 Group 3 PWC 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 thatthe enrollee does not meet the criteria for coverage. Our physician reviewer found the records show that the enrollee has a personal mobility deficit that impairs participation in mobility-related activities of daily living (MRADLs) in the home that is unable to be helped by a walker or cane due to weakness. There is no objective physical exam of the upper and lower extremities that would indicate he cannot operate a manual wheelchair. The documentation does not indicate that the enrollee is unable to perform a functional weight shift as he can stand and ambulate. The documentation does not reveal he utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed. The physician documentation does not support that he requires a power seating system to manage increased tone or spasticity as there is no documentation of this or an objective physical exam. The requested Group 3 power wheelchair with multiple power options 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 3power wheelchair (PWC) with multiple power options
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 29, 2020 by an out of network provider.
You asked the Plan to pay for the Domiciliary or rest home visit for the evaluation and management of an established patient (92548). You say that the Plan has paid these claims in the past. The Plan denied your request. The Plan says you did not request prior authorization for the non-urgent services.
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 services 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 these services. Therefore, we decided that the Plan does not have to pay for the medical services provided on February 29, 2020 by an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea interspinous and/or interlaminar device (22869, 22870).You asked the Plan to pre-approvea interspinous and/or interlaminar device. 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 items andservices 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 a interspinous and/or interlaminar device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.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 interspinous and/or interlaminar device have not been met.Therefore, we decided that the Plan does not have to pre-approvea interspinous and/or interlaminar device (22869, 22870).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the documentation provided, the enrollee no longer qualifies for SNF coverage.  The enrollee does not have documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point, can be provided at a lower 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora blood smear (85060) provided on January 29, 2020.You asked the Plan to pay forthe blood smear. You say that you would like reconsideration because this procedure was rendered in an appropriate place of service.The Plan denied your request. The Plan says payment for this CPT code is only made for the professional component of the code for hospital inpatient.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that no payment is recognized for code 85060 furnished to hospital outpatients or non-hospital patients.We find that CPT code 85060 is not supported in the record. Specifically, this claim was billed with place of service code 22 for on-campus outpatient hospital. No payment for this CPT code is recognized for hospital outpatients. Based on this information, we decided that Medicare rules for coverage of the blood smear have not been met.Therefore, we decided that the Plan does not have to pay fora blood smear (85060) provided on January 29, 2020
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided on March 3, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the billed codes are not supported.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was 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 forthe drug testing services provided on March 3, 2020.
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-approve foot orthotics. You say that you are not walking well. 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-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that your feet hurt and cannot stand for long.The Plan denied your request. The Plan says this item is not a coveredbenefit.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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea positron emission tomography (PET) scan.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has prostate cancer with pelvic side wall adenopathy. The criteria for coverage of the requested PET scan are not met. The enrollee is not previously treated. The PET scan is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvea positron emission tomography (PET) scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on February 3, 2020.You asked the Plan to pay forthe ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 3, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean oral thermometer.You asked the Plan to pre-approvethe oral thermometer. You say that you have yourtemperature checked by home health personnel and you want to have your own thermometer to double check if their reading is high so you do not need to go to the hospital due to an incorrect reading.The Plan denied your request. The Plan says this is nota Medicare-covered item.The Plan must follow Medicare rules. Medicare rules say that, generally, items can only be covered by Medicare when they meet the definition of DME, as described above, and are reasonable and necessary. Although an oral thermometer does provide information which may be useful, it does not directly diagnose a medical condition. In addition, it does not meet the definition of durability since it is not the type of item that could be rented. Though this may be a reasonable item for you, it does not meet the Medicare rules for coverage.Therefore, we decided that the Plan does not have to pre-approvean oral thermometer.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pay forstandardized cognitive performance testing (96125) provided on April 8, 2020.You asked the Plan to pay forthe testing. You say that you would like reconsideration because the services rendered were medically necessary and are a covered benefit.The Plan denied your request. The Plan says that CPT code 96125 has a Professional Component (PC)/Technical Component (TC) indicator of 7 per the April 2020 National Physician Fee Schedule Relative Value File.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 96125 is supported in the record. Specifically, the record indicates that the therapy services were rendered via telehealth communication. There is no indication that the member was a hospital inpatient or outpatient. Based on this information, we decided that Medicare rules for coverage of the testing have been met.Therefore, we decided that the Plan has to pay forstandardized cognitive performance testing (96125) provided on April 8, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Retacrit.

You asked the Plan to pre-approve Retacrit. The Plan denied your request. The Plan says the enrollee's levels were not below the required blood hormone level.

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 Retacrit. Our physician reviewer found that myelomonocytic leukemia, with 2 -8% granulated blasts. The enrollee is unlikely to respond to erythropoiesis-stimulating agent with an erythropoietin level greater than 1000. The documentationdoes not support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Retacrit have not been met.Therefore, we decided that the Plan does not have to pre-approve Retacrit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient office visit (99213) skin biopsy (11002) level IV surgical pathology, gross and microscopic examination (88305) provided March 5, 2020.
You asked the Plan to pay for the office visit. You say that you need the benefits to be paid directly to you at your residence. The Plan denied your request. The Plan says missing or zero charge amount.
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, there were no charge amounts on the claim form submitted for the services rendered. The provider must submit a corrected claim. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for outpatient office visit (99213) skin biopsy (11002) level IV surgical pathology, gross and microscopic examination (88305) provided March 5, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on June 26, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 26, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on June 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHydromorphone and Bupivacaine through an intrathecal pump.You asked the Plan to pre-approvethe requested services. You say that the enrollee has attempted alternate treatments that have been unsuccessful.The Plan denied your request. The Plan says the requested drugs are not FDA-approved for intrathecal administration.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We looked at the file, and Medicare rules.In this case, there are insufficient records showing that it is necessary to administer the requested drugs through an intrathecal pump over other avenues.Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plandoes not have to pre-approveHydromorphone and Bupivacaine through an intrathecal pump.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on May 14, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthe home visit and medical nutrition (99345 and 97802). You say that you would like reconsideration because authorization should not be needed for telemedicine.The Plan denied your request. The Plan says the services were not referred by a network provider, rendered in a participating facility, urgent or emergent.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 involvingemergencies, 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 notpre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on May 14, 2020, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome health services (G0156).You asked the Plan to pre-approvethe home health services. You say that the services are medically necessary.The Plan denied your request. The Plan says the enrollee does not require skilled home care.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the home health services. Our reviewer says that the home health services are not medically necessary. Our physician reviewer found there is no evidence to show that the enrollee qualifies for, or is receiving, home skilled nursing or home skilled therapy services.We looked at this physician's review, the file, andMedicare rules. Based on this information, we decided that
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe destruction and/or removal of large growths of the bladder (52240) provided on May 15, 2020, by an out of network (OON) provider.You asked the Plan to waive the coinsurance forthe destruction and/or removal of large growths of the bladder. You saythat you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the coinsurance applied correctly in this case.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 40% coinsurance for OON outpatient surgery. You have been asked to pay a 40% coinsurance for the destruction and/or removal of large growths of the bladder. This servicefalls within the OON 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 coinsurance forthe destruction and/or removal of large growths of the bladder (52240) provided on May 15, 2020, by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for dental services provided on March 3, 2020.
You asked the Plan to reimburse you for the dental services. You say that the Plan has paid for claims from this
provider in the past. The Plan denied your request. The Plan says the provider is ineligible for payment from
Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary
for items or services provided directly by a physician or practitioner who has opted out of the program except
in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to reimburse you for
dental services provided on March 3, 2020.