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

We decided that the Plan has to pre-approveimage guided radiation therapy (IGRT).You asked the Plan to pre-approvethe IGRT. You say that the target volumeis in close proximity to critical structures that must be protected.The Plan denied your request. The Plan says that IGRT is 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 thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the IGRT. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has metastatic renal cell cancer of the lumbar spine. The IGRT is being requested because the enrollee's provider believes it is needed to spare normal structures. The National Comprehensive Cancer Network and compendiassupport the use of IGRT as a category 2A recommendation and it is an appropriate form of treatment 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 ofthe IGRT have been met.Therefore, we decided that the Plan has to pre-approveimage guided radiation therapy (IGRT).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 therewas 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-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. 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 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 required supervision for bed rolling. The enrollee required minimal assistance for sit up, stand up, toilet transfers via transfer technique, and sponge bathing. The enrollee required minimal/moderate assistance for upper and lower body dressing. The enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 27, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on December 27, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the crisis intervention mental health services provided on March 13, 2020.
You asked the Plan to waive the copayment for the crisis intervention mental health services. You say that you should not be responsible for the copayment because you do not have a mental health issue and should not have gone to the emergency room. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $40 copayment per Medicare-covered visit. You have been asked to pay a $40 copayment for the crisis intervention mental health services. The crisis intervention mental health services fall within the "Outpatient mental health care" benefit category. The medical record shows you received crisis intervention services.
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 crisis intervention mental health services provided on March 13, 2020.
Your complaint that the services were fraudulent is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that these services were referred by a provider. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these 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 items/services at issue in this appeal. The Plan did not pre-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 for lab tests provided on October 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for back injections (64494 and 64495) provided on February 18, 2020.
You asked the Plan to pay for the back injections. You say that you would like the coding errors of this claim explained. The Plan denied your request. The Plan says these services are only allowed once per date of service.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUEs for CPT codes 64494 and 94495 is 1. The provider billed 2 units of these codes, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the back injections have not been met. Therefore, we decided that the Plan does not have to pay for back injections (64494 and 64495) provided on February 18, 2020.
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 enrollee requires the services. The Plan denied
your request. The Plan says the enrollee does not meet Medicare criteria for admission in an IRF.
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 does not require the intensity of services provided at an IRF.
Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular
physician evaluation. The enrollee's care needs can be met 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 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 Dexcom G6 and accessories (K0553, K0554).
You asked the Plan to pre-approve a Dexcom G6 and accessories. You say that the requested items 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 the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Dexcom G6 and accessories have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 and accessories (K0553, K0554).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services (CPT 87798) provided on February 4, 2020.You asked the Plan to pay forthe 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 testing at issue in this appeal was 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 forthe lab services (CPT 87798) provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider podiatry provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary due to a foot infection.The Plan denied your request. The Plan says the referred to provider is not contracted for podiatry service, and you do not qualify for routine foot care.The Plan must follow Medicare rules. The rules say that routine foot care is not a covered Medicare benefit unless you have diabetic foot disease or some other condition that makes professional care of your feet 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 referral. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. We looked at this doctor's review, the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the referral have not been met.Therefore, we decidedthat the Plan does not have to pre-approvea referral to an out-of-network provider podiatry provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe urological supplies provided on February 24, 2020.You asked the Plan to pay forthe urological supplies. You say that the Plan should pay this claim.The Plandenied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. The rules say that Medicare does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. Theses supplies would have been included in the global payment submitted to the plan by the facility. Records show that the ostomy supplies wereused in a SNF.Therefore, we decided that the Plan does not have to pay forthe urological supplies provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasound therapy (97035), electrical stimulation (97014),
and traction therapy (97012) provided by a chiropractor from January 13, 2020 to February 10, 2020.
You asked the Plan to pay for ultrasound therapy, electrical stimulation, and traction therapy. You say that you
were told these services would be covered. The Plan denied your request. The Plan says these services are not
covered by Medicare or the Plan.
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.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for ultrasound therapy (97035), electrical stimulation (97014), and traction
therapy (97012) provided by a chiropractor from January 13, 2020 to February 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foam dressings, wound cover, sterile, pad size 16 s
(A6209).
You asked the Plan to pre-approve foam dressings. You say that the requested items are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that surgical dressings are covered when a qualifying
wound is present.
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 foam dressings. Our reviewer says that
the items are not medically necessary. Our physician reviewer found based on the medical records provided the
enrollee does not meet the coverage criteria.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of foam dressings have not been met. Therefore, we decided that the Plan does not
have to pre-approve foam dressings, wound cover, sterile, pad size 16 s (A6209).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a laparoscopy (47563) provided on November 21, 2019.
You asked the Plan to pay for the laparoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 47563 is laparoscopy, surgical; cholecystectomy with cholangiography. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the laparoscopy. Our reviewer says that CPT code 47563 does not meet criteria for billing or reimbursement consideration. Our reviewer found the surgical report does on indicate that a cholangiography was performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laparoscopy have not been met. Therefore, we decided that the Plan does not have to pay for a laparoscopy (47563) provided on November 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. 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. 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 the enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in askilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve high intensity focused ultrasound (HIFU) ablation and associated procedure.

You asked the Plan to pre-approve high intensity focused ultrasound ablation and associated procedure. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that HIFU is only covered for certain indications.

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 high intensity focused ultrasound ablation and associated procedure. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has an elevated PSA of 7.49 ng/mL that was evaluated with needle biopsy on May 1, 2020. Pathology revealed stage T1c Gleason's grade 3+4 adenocarcinoma involving 3 of 12 core biopsies. The LCD criteria have not been met. These criteria only cover HIFU as a salvage treatment for radiation failures. The medical records indicate that the enrollee has not been treated with radiation or any other treatment. Therefore, the enrollee does not meet criteria for the requested 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 high intensity focused ultrasound ablation and associated procedure have not been met.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 27, 2020.
You asked the Plan to pay for the assembly and operation of a pump with an oxygenator or heat exchanger. You say that this service was required. The Plan denied your request. The Plan says payment for this service is included in the DRG.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2020 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forcomprehensive oral exam (D0150) intraoral -complete series x-rays (D0210) provided February 20, 2020.You asked the Plan to pay forthe dental services. You say that it was necessary for your new dental provider to perform these two services in order to make an accurate and thorough diagnosis. You were experiencing dental problems and ongoing pain.The Plan denied your request. The Plan says the service exceeds the benefit frequency limitation.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Comprehensive exam's and complete services x-rays are covered once every 3 years and records show that these services were provided on September 30, 2019.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forcomprehensive oral exam (D0150) intraoral -complete series x-rays (D0210) provided February 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on October 3, 2019.You asked the Plan to pay forthe assembly and operation of a pump with an oxygenator or heat exchanger. You say that this is a mandatory service.The Plan denied your request. The Plan says payment for this service is included in the DRG.The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission.Therefore, we decided that the Plan does not have to pay for the assembly and operation of a pump with an oxygenator or heat exchanger (99190) provided on October3, 2019.