Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
You asked the Plan to pre-approve the interspinous spacer placement. You say that the spacer placement is medically necessary. The Plan denied your request. The Plan says the requested procedure is considered investigational at this time and is not covered.
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 interspinous spacer placement. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found a recent medical literature review from 2020 summarized that the effectiveness of interspinous device placement is still being debated as there is only modest evidence for its effectiveness. More supportive evidence is needed before this procedure can be considered a standard 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 the interspinous spacer placement have not been met. Therefore, we decided that the Plan does not have to pre-approve an interspinous spacer placement (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9338) provided on March 26, 2020, through March 30, 2020.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code S9338 has a status indicator of I and is not valid for Medicare purposes.
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 S9338 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9338 has a status indicator of I. This means that this code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9338) provided on March 26, 2020, through March 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on October 19, 2020.
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk testing, except the basic lipid panel.
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 test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the hereditary cardiovascular genetic testing provided on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says the services can be safely received in other settings, for example: a skilled nursing, home with home health services, or home with outpatient therapy.
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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for confusion, hypotension and cellulitis of the legs. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the determination of refractive state (92015) provided on October 28, 2020.
You asked the Plan to pay for the eye refraction. You say that this was an important part of the eye exam and it should be covered. The Plan denied your request. The Plan says that refractions are only covered when provided as part of a routine vision exam. The refraction provided was billed with a pre-existing diagnosis, which means that the exam is considered medical or diagnostic and not routine. Therefore, the refraction is not covered.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided as part of a routine exam. We looked at the file and the Plan's rules. This service was billed with a diagnosis, which means that the refraction provided was medical in nature and not routine. Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met. Therefore, we decided that the Plan does not have to pay for the determination of refractive state (92015) provided on October 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on November 17, 2020.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the laboratory services. 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 laboratory services provided on November 17, 2020.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the pelvis.

You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says that the doctor's notes do not show other tests that have been done for this problem.

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 medically reasonable and necessary. Our physician reviewer found the clinician's notes have included detailed discussion concerning a planned left total hip arthroplasty to which the enrollee agreed. CT scanning including 3D rendering is standard in patients with severe degenerative OA considering this surgery, since careful attention must be made to joint appliance selection, especially considering the potential of limb length discrepancy associated with the surgery. CT of the pelvis should be approved.

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 been met. Therefore, we decided that the Plan has to pre-approve CT scan of the pelvis.

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 Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve the Dexcom G6 brand CGM. You say that this device is necessary as the enrollee has morning lows and needs the CGM alarm to warn about this. The Plan denied your request. The Plan says the preferred brand can be used without any issue. The non-preferred brand is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that plans are allowed to restrict enrollees to certain brand of durable medical equipment unless a non-preferred brand is medically necessary. We looked at the file and Medicare rules. The preferred brand offered by the Plan is Freestyle Libre. We do not see any objective evidence or argument supporting that only the Dexcom G6 can be used or that the Freestyle Libre would not meet the enrollee's needs. We find that the rules for coverage of the non-preferred brand have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health aide services (S9122) provided from September 2, 2019, to November 28, 2019.
You asked the Plan to pay for home health aide services. You say that this should be covered. The Plan denied your request. The Plan says these services are not documented.
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 S9122 is not supported in the medical record. Specifically, no documentation of home health services being performed has been submitted. Furthermore, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the Plan does not have to pay for home health aide services (S9122) provided from September 2, 2019, to November 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from September 14, 2020, to September 17, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you have Alzheimer's Disease. You say that you cannot self-administered anything. The Plan denied your request. The Plan says the drugs that you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from September 14, 2020, to September 17, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Medical Necessities Bag Hooks (K0108), Transfer Handle (K0108), Seat Elevator (E2300), Electronic connection (E2311), Expandable Controller (E2377) and Expandable Controller Harness (E2313).
You asked the Plan to pre-approve the power mobility device accessories and parts. You say that the remaining codes should be overturned. The Plan denied your request. The Plan says that it agreed that some of the power wheelchair parts were necessary, but not the codes defined by K0108, E2300, E2311, E2377, and E2313.
The Plan must follow Medicare rules. Medicare rules say that E2300 Seat Elevator does not serve a primary medical purpose and is statutorily non-covered. The Electronic Connection (E2311), Expandable Controller (E2377) and Expandable Controller Harness (E2313) cannot be covered as it is not medically necessary to control the three approved power options through the joystick (drive interface). The requested K0108 Bag Hooks are a non-medical feature. This item is not considered DME and is also statutorily not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power mobility device accessories and parts have not been met. Therefore, we decided that the Plan does not have to pre-approve Medical Necessities Bag Hooks (K0108), Transfer Handle (K0108), Seat Elevator (E2300), Electronic connection (E2311), Expandable Controller (E2377) and Expandable Controller Harness (E2313).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020,
to February 19, 2020.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required
and received are coverable under the Medicare Act. The Plan denied your request. The Plan says Skilled
Nursing Facility (SNF) care beyond 100 days per benefit period is not covered by Medicare or the Plan.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period from October 11,
2019, to January 23, 2020. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has
not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided
that the Plan does not have to pay for the skilled nursing services provided from January 24, 2020, to February
19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient mental health stay provided from July 14, 2020, to July 17, 2020.

You asked the Plan to waive the copayment for an inpatient mental health stay. You say that you should not be responsible for the charges due to the quality of care received. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $175 copayment for days 1-7 for inpatient mental health care. 

You had an inpatient hospital mental health stay from July 14, 2020, to July 17, 2020. Therefore, you are responsible to pay a $175 copayment for days 1-3 (July 14, 2020, to July 16, 2020). $175 (copayment) x 3 (inpatient days) = $525. 

You have been asked to pay the total copayment amount of $525 for an inpatient mental health stay. An inpatient mental health stay falls within the inpatient mental health 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 an inpatient mental health stay provided from July 14, 2020, to July 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a scooter lift for van (E1399).

You asked the Plan to pre-approve a scooter lift for van. You say that this item is necessary to help you get into a vehicle. The Plan denied your request. The Plan says this item is not covered.

The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a scooter lift for van (E1399).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) machine.

You asked the Plan to pre-approve a CPAP machine. You say that the requested CPAP machine is medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet criteria for the requested CPAP machine.

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 a CPAP machine. Our reviewer says that the enrollee meets criteria for the requested CPAP machine. Our physician reviewer found the enrollee is with obstructive sleep apnea who has been using a continuous positive airway pressure device (CPAP). Coverage for the CPAP device has been requested. At issue in this case is whether the CPAP device is eligible for coverage under Medicare guidelines. The health plan denied coverage for the CPAP device stating that the available medical records do not support necessity of the device as defined by Medicare criteria as compliance data with use of the device did not meet the minimum standard. 

Based on the medical records provided (including a CPAP compliance report provided on 04/05/2021) there is documentation that the enrollee meets the Local Coverage Determination (LCD): Positive Airway Pressure (PAP) Devices for the treatment of Obstructive Sleep Apnea (L33718) criteria for the requested continuous positive airway pressure device (CPAP). The additional information provided in the above referenced compliance report included data from 02/01/2021 - 03/30/2021 indicating usage of the CPAP device greater than or equal to 4 hours per night for 96.6% of the time. Records also indicate improvement in the enrollee's sleep apnea symptoms with use of the CPAP.

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 CPAP machine have been met. Therefore, we decided that the Plan has to pre-approve a continuous positive airway pressure (CPAP) machine.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation.

You asked the Plan to pay for the psychiatric diagnostic evaluation (90792). You say that you did not receive proper notice of the enrollee's benefit determination. The Plan denied your request. The Plan says the corrected claim was untimely.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the psychiatric diagnostic evaluation (90792) was not filed until August 28, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the psychiatric diagnostic evaluation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the infusion pump and supplies provided on January 16, 2020.
You asked the Plan to pay for the infusion pump (E0781) and supplies (A4222). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the drug received does not require this special pump and are not on the Medicare list of approved medications that require a pump.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Cefazolin and daptomycin are not listed as medications that require a pump. The record shows the medications can be given in 60 minutes or less. Based on this information, we decided that Medicare rules for coverage of the infusion pump and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the infusion pump and supplies provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the power seat elevation system (E2300).
You asked the Plan to pre-approve the power seat elevation system. You say that you would like this item covered. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the power seat elevation system (E2300).