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

We decided that the Plan does not have to pre-approve a bilateral L4-S1 medial branch block for the enrollee. You asked the Plan to pre-approve the block. You say that relief has been received from these injections in the past.The Plan denied your request. The Plan says this is not indicated for radicular pain.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 block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has both spinal stenosis as well as lumbar radicular symptoms. 
These are probable alternate pain generators and therefore, the criteria of the LCD are not met. The requested procedure is not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the block have not been met.Therefore, we decided that the Plan does not have to pre-approve a bilateral L4-S1 medial branch block.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a nephrology visit at the tertiary level of care with the practice. You asked the Plan to pre-approve tertiary nephrology visit. You say that you have a rare disease and were directed to this provider to get better care.The Plan denied your request. The Plan says that the denial of authorization for this service is correct, because you can be treated by a non-tertiary nephrologist. 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 tertiary nephrology visit. Our reviewer says that the requested tertiary level of care is medically necessary for you. Our physician reviewer found your condition is very rare. A typical nephrologist will not encounter this condition in his/her typical practice. It should be managed at tertiary care centers as they offer a level of expertise for this rare and serious condition. It is appropriate for your condition to be managed at the tertiary 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 tertiary nephrology visit have been met. Therefore, we decided that the Plan has to pre-approve a nephrology visit at the tertiary level of care with the practice.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Superion Vertiflex Device.You asked the Plan to pre-approve the Superion Vertiflex Device. You say that the device is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says this device is not covered because the member is not a participant in a clinical study.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 Superion Vertiflex Device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed.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 Superion Vertiflex Device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Superion Vertiflex Device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not need intensive physical or occupational therapies.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 physician reviewer found that you have been discharged from physical and occupational (PT and OT) therapy. You have reached your previous level of function, and you exhibit little to no functional deficits. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that you require the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of PT and OT, but you do not require this on an intensive rehabilitation facility therapy program level 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex interspinous device for the enrollee.You asked the Plan to pre-approve the requested services. You say that the insertion of the device would provide significant clinical and quality of life for the enrollee.The Plan denied your request. The Plan says a body mass index of 40 or more is a contraindication to the Vertiflex device.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 requested services. Our physician reviewer found that the requested device is considered experimental as more research is needed to prove its efficacy. Therefore, the requested device is not medically reasonable and necessary to treat 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex interspinous device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652). You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided from July 23, 2019 to October 11, 2019.You asked the Plan to pay fo rthe diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided from July 23, 2019 to October 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wrist-hand orthosis (L3916) provided to the enrollee on February 19, 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 fora wrist-hand orthosis (L3916) provided to the enrollee on February 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a neuromuscular diagnostic procedure (95999) provided August 14, 2019 by the practice.You asked the Plan to pay for the neuromuscular diagnostic procedure. You say that the services were medically necessary.The Plan denied your request. The Plan says code 95999 (Train-Of-Four testing) shares a bundled relationship with G0453 (Continuous intraoperative neurophysiology monitoring) which was already approved for payment.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, we have confirmed that code the neuromuscular diagnostic procedure (95999) has a bundled relationship with Continuous Intraoperative Neurophysiology Monitoring (G0453) and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met.Therefore, we decided that the Plan does not have to pay for a neuromuscular diagnostic procedure (95999) provided August 14, 2019 by the practice.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 24, 2019 by out of network provider. You asked the Plan to pay for the physician services. You say that the services were medically necessary and the enrollee was staying in a facility.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider.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 the medical services provided on April 24, 2019 by out of network provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve endovenous ablation therapy (36478) and stab phlebectomy (37766) procedures to treat varicose veins. You asked the Plan to pre-approve varicose vein treatment procedures. You say that the pain in your legs makes it difficult to exercise and lose weight to meet criteria.The Plan denied your request. The Plan says that the denial of authorization for these services is correct, because your body-mass index (BMI) is not within the Medicare coverage range of less than 35. The Plan follows Medicare rules. Medicare rules say that treatment for varicose veins may be considered medically necessary under certain conditions.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 varicose vein treatment procedures. Our reviewer says that the enrollee meets the Medicare criteria for the requested procedures. Our physician reviewer found there is satisfactory documentation of symptoms that can be attributed to the varicose veins severe enough to affect quality of life that have failed conservative treatments, including medical grade compression stockings. There is satisfactory documentation of significant reflux in the veins to be treated and documentation of normal lower extremity pulses and absence of deep venous thrombosis (DVT). Although the enrollee is not within the stated body-mass index (BMI) range, there is sufficient documentation of medical necessity to override the denial based on this single criteria. These services are medically reasonable and necessary for the enrollee at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of varicose vein treatment procedures have been met. Therefore, we decided that the Plan has to pre-approve endovenous ablation therapy (36478) and stab phlebectomy (37766) procedures to treat varicose veins.
If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (G0453, 95955, 95938) provided July 9, 2018 by the practice.You asked the Plan to pay for the physician services. You say that the claim was submitted timely.The Plan denied your request. The Plan says the claim was filed 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 physician services was not filed until July 23, 2019. 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 physician services (G0453, 95955, 95938) provided July 9, 2018 by the practice.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services for nail debridement provided by the physician on April 24, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 services 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 physician's services for nail debridement provided on April 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided by the physician on May 1, 2019.You asked the Plan to pay for the physician's services.The Plan denied your request. The Plan says non-urgent, non-emergent services require prior authorization. The Plan requires utilization of network providers when possible and available.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 physician's 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 physician's services provided by the physician on May 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oxygen concentrator.You asked the Plan to pre-approve an oxygen concentrator. You say that you need oxygen until you're able to use a CPAP machine again.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. 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 an oxygen concentrator. Our physician reviewer found that the  medical record includes vital signs from the ED visit for the facial trauma, which shows a single low oxygen saturation of 84%, which resolved 1 minute later without apparent treatment or oxygen. All of the remaining oxygen saturations were well above 90%.  There is no evidence that oxygen supplementation is beneficial in the treatment of hypoxemia due to obstructive sleep apnea. Medicare does not cover oxygen in the absence of CPAP. There is no documentation of sustained hypoxemia. Therefore, oxygen supplementation 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 an oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve an oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided to the enrollee on December 26, 2018.You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plan says the enrollee enrolled in hospice from December 18, 2018 to December 30, 2018. The plan states, per Medicare guidelines, the provider must bill Original Medicare for the services rendered on December 26, 2018.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the physician services provided to the enrollee on December 26, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided from July 3, 2019 through September 3, 2019.You asked the Plan to waive the coinsurance for the oxygen concentrator. You say that you should be able to pay the previous price for this item.The Plan denied your request. The Plan says that this processed correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Durable medical equipment (DME) and related supplies. You have been asked to pay 20% coinsurance for the oxygen concentrator. The oxygen concentrator falls within the Durable medical equipment (DME) and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for the oxygen concentrator provided from July 3, 2019 through September 3, 2019