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

We decided that the Plan does not have to pre-approve a heavy duty manual wheelchair and seat cushion.
You asked the Plan to pre-approve the manual wheelchair. You say that you need this wheelchair for use in the home because you were told that you should charge your power wheelchair for 24 hours straight at least once per week. During that time, you need the manual chair to do your activities in the home. The Plan denied your request. The Plan says this second piece of mobility equipment is not considered reasonable and necessary as you have been provided with a power wheelchair.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a power wheelchair. A power wheelchair serves the same purpose as the manual wheelchair. Therefore, we decided that the Plan does not have to pre-approve a heavy duty manual wheelchair and seat cushion.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98941, 98942).
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the requested service is not medically necessary.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
We looked at the case file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of this service have not been met. Specifically, the medical records provided do not indicate
that the enrollee has a subluxation of the spine demonstrated by x-ray or physical exam. Therefore, we decided
that the Plan does not have to pre-approve chiropractic manipulative treatment (98941, 98942).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the acute care hospital is able to provide all of the services the enrollee requires. The enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe refractive lenses rendered on September 19, 2019 to October 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. "...rules for SNF care have not been met."]The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear.Therefore, we decided that the Plan does not have to pay forthe refractive lenses rendered on September 19, 2019 to October 24, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on November 9, 2019.
You asked the Plan to pay for the ambulance services. You say that you thought you were having an allergic reaction and you panicked and called for an ambulance. The Plan denied your request. The Plan says you could have been safely transported in another type of vehicle.
Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the service was not medically necessary. Our physician reviewer found you did not meet the requirement for the ground ambulance services. You were alert and oriented with stable vital signs and no physical examination abnormalities. The documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for you. The documentation does not support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport. The documentation does not support that the ambulance transport was medically reasonable and necessary for you. 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 ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 9, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found you are currently undergoing treatment at an acute care hospital for acute renal failure, which is noted to be improving. You are not intubated/ventilated. There is no evidence that you require services that are not currently available. As LTACHs and acute care hospitals are licensed to provide the same level of care, there is no advantage in transferring you to the LTACH. You can remain at the current acute care hospital until such time no acute services are required.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services (CPT 99350) provided to the enrollee on August 16, 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 the documentation indicates the services are not necessary for treatment of the enrollee's condition.
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 99350 is "Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent face-to-face with the patient and/or family." 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 there is documentation of an LPN/LVN skilled nursing visit on 8/16/19. Home and domiciliary visits are when a physician or qualified non-physician practitioner (NPPs) oversee or directly provide progressively more sophisticated evaluation and management (E/M) visits in a beneficiary's home. The documentation does not support the coding of CPT 99350. 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 Plan does not have to pay for home health care services (CPT 99350) provided to the enrollee on August 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration because if a lower level of care will cause major setbacks in the member's health and improvement.The Plan denied your request. The Plan says the services may be rendered at a lower level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 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 laboratory services, were requested solely for screening purposes. Medicare does not cover these tests solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 15, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device.
You asked the Plan to pre-approve TENS device. You say that you are appealing the denial of pain patches for your back that was requested by your doctor. The Plan denied your request. The Plan says this request is not medically necessary at this time. The plan has instead approved physical therapy.
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 TENS device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found TENS is not reasonable and necessary for this enrollee at this time. The enrollee has chronic low back pain for which a TENS unit is not indicated. The TENS is not more medically appropriate than the physical therapy the plan is offering. The plan's denial is medically justified in that it is offering to meet the enrollee's needs through therapy. The physical therapy the plan is offering is the standard of care for the treatment of the enrollee's condition We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TENS device have not been met. Therefore, we decided that the Plan does not have to pre-approve transcutaneous electrical nerve stimulation (TENS) device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 7, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 67036 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 67036 and 66852. Code 67036 is a column II code with a modifier indicator of 1 when billed with column I code 66852. Code 67036 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on November 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the placement of the Watchman Left Atrial Appendage
Occlusion Device on January 9, 2020.
You asked the Plan to pay for the placement of the Watchman Left Atrial Appendage Occlusion Device. You
say that the placement of the Watchman Left Atrial Appendage Occlusion Device meets criteria. The Plan
denied your request. The Plan says the placement of the Watchman Left Atrial Appendage Occlusion Device
did not meet criteria.
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 pay for the placement of the Watchman Left Atrial
Appendage Occlusion Device. Our reviewer says that the placement of the Watchman Left Atrial Appendage
Occlusion Device did not meet criteria. Our physician reviewer found the enrollee is with a history of
hypertension, coronary artery disease, carotid endarterectomy, cholecystectomy and atrial fibrillation. A clinic
note dated 12/19/19 documents "hemorrhaging" while on apixaban but no bleeding while on warfarin. He
underwent Watchman device placement on 01/09/2020.
Based on the records the enrollee has atrial fibrillation, bleeding on apixaban that is not detailed, no bleeding
on warfarin and no documented transesophageal echocardiogram to determine suitable anatomy for Watchman
device placement. In this circumstance the records do not support the medical necessity for placement of a
Watchman Device. Coverage criteria are not met since one requirement that is not documented is " A formal
shared decision making interaction with an independent non-interventional physician using an evidence-based
decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the shared decision
making interaction must be documented in the medical record. A suitability for short-term warfarin but deemed
unable to take long-term oral anticoagulation following the conclusion of shared decision making". In this case
bleeding on apixaban is not further detailed and there is no bleeding on warfarin.
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 placement of the Watchman Left Atrial Appendage Occlusion Device have
not been met. Therefore, we decided that the Plan does not have to pay for the placement of the Watchman Left
Atrial Appendage Occlusion Device on January 9, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Gastrointestinal Pathogen xTag PCR testing provided on
November 25, 2019.
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically
necessary.
The Plan follows Medicare rules. Medicare rules say that GIP panels are covered when the above 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 pay for the testing. Our reviewer says that the
requested testing was not medically reasonable and necessary. Our physician reviewer found that
Gastrointestinal Pathogen xTag PCR testing was ordered. The Statement of Medical Necessity was noted to be
chronic unexplained diarrhea. The clinical medical records in the case file are limited to the order form and the
results of the testing. There is no documentation of differential diagnoses such as celiac disease, Crohn's
disease, eosinophilic gastroenteritis, or Whipple's disease. The documentation does not support that the
coverage criteria for the testing at issue, as established by the LCD, have been met in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have
to pay for the Gastrointestinal Pathogen xTag PCR testing provided on November 25, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for after-hours services (99053) provided November 12, 2019.
You asked the Plan to pay for the after-hours services. You say that the services were medically necessary. The
Plan denied your request. The Plan says separate payment cannot be made for code 99053.
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 99053 is not supported in the medical record. Specifically,
rules say that for codes with status "B", payment for covered services are always bundled into payment for
other services not specified. There will be no Relative Value Units (RVUs) or payment amounts for these codes
and no separate payment is ever made. Code 99053 is marked with status "B". Payment for the service is
bundled in the approved emergency room services. Based on this information, we decided that Medicare rules
for coverage of the after-hours services have not been met. Therefore, we decided that the Plan does not have to
pay for after-hours services (99053) provided November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custom foot orthotics.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
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 the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the lab services you received on June 24,
2019, and January 27, 2020.
You asked the Plan to waive the copayment. You say that you should have no copayment. The Plan denied
your request. The Plan says you are responsible for the copayment.
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
copayment for lab services at an outpatient hospital setting.
Review of the file shows that you were provided lab services on June 24, 2019, and January 27, 2020. You
have been asked to pay a $40 copayment for the services on June 24, 2019. The services fall within the
outpatient diagnostic tests benefit category. You have also been asked to pay a $22.20 copayment for the lab
services on January 27, 2020, as the Medicare allowed amount for these services was less than the $40
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 copayment for the lab services you received on June 24,
2019, and January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that this physician is a specialist in this field and the enrollee has been seeing him for several years and is not able to get this care in her area. The Plan denied your request. The Plan says the Plan has providers in-network that can provide the requested 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 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. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested physician's services.