Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe outpatient mental health services (99213) provided on April 29, 2019.You asked the Plan to pay forthe outpatient mental health services.. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were in-network providers that could have provided the services at issue.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe outpatient mental health services (99213) provided on April 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and sleeve (L0648) provided March 1, 2019.You asked the Plan to pay forthe orthoses. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the records provided do not support the service billed.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 non-covered visit are likewise non-covered.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) and sleeve (L0648) provided March 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveInfliximab for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee's diagnosis is not an accepted indication for this drug.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine ifthe Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found a review of the compendia does not support the use of infliximab for the provided diagnosis. Without the support of the documentation, medical necessity cannot be determined.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 drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveInfliximab for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee from December 30, 2019 through January 12, 2020.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health care. Our physician reviewer found this enrollee did not appear to require inpatient mental health treatment beyond the date in question as she was not a danger to herself or others and did not have any auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services were reasonably expected to improve the patient's condition or for the purpose of diagnosis beyond the date in question. I am unable to find an individualized treatment plan however the entire chart is not present. It did appear that the records were supervised and evaluated by a physician. Based upon review the records provided for the admission of this patient does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of December 30, 2019 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations not requiring 24-hour inpatient treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee from December 30, 2019 through January 12, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve septoplasty with inferior turbinectomy for the enrollee.
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your request. The Plan says there is no documentation of the conservative treatments that have been tried.
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 surgery. Our reviewer says that the requested surgery is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that septoplasty and inferior turbinectomy are medically reasonable and necessary for the enrollee in this case, as there is no documentation of an allergy assessment, and trial and failure of conservative measures. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve septoplasty with inferior turbinectomy for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

e decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee. You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee no longer has acute symptoms that require 24-hour care. The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  The file shows that continued services beyond February 5, 2020 was requested for 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 continued services. Our physician reviewer found that active treatment was not taking place. The services were not reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. This enrollee was treated under an individualized treatment plan found in the record. He was not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions and was not showing any behaviors being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient behavioral health services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you want to continue to see this doctor that was suggested to you. The Plan denied your request. The Plan says it was determined that there are in-network providers 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. The Plan denied your request. The Plan says that you are currently medically stable and do not require daily skilled nursing care.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for wrist/hand orthosis (L3916) provided August 15, 2019.
You asked the Plan to pay for the orthosis. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no evidence of an established relationship between the enrollee and the ordering physician, the documentation does not identify the enrollee's originating site at the time of the telehealth visit, there was no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth service with the ordering physician as required per CMS guidelines.
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 non-covered visit are likewise non-covered. Therefore, we decided that the Plan does not have to pay for wrist/hand orthosis (L3916) provided August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Flexitouch pneumatic compression device (E0652) and segmented appliance/sleeve (E0667).You asked the Plan to pre-approvethe Flexitouch device and appliance/sleeve. You say that the enrollee had poor results with a basic and now needs the Flexitouch 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 must follow Medicare rules. Medicare rules say 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. In this instance, 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. Based on this information, we decided that Medicare rules for coverage of the Flexitouch device and appliance/sleeve have not been met.Therefore, we decided that the Plan does not have to pre-approvea Flexitouch pneumaticcompression device (E0652) and segmented appliance/sleeve (E0667).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for an inpatient hospital stay provided from May 30, 2019 to June 5, 2019.
You asked the Plan to pay for inpatient hospital stay. You say that you did not have the enrollee's insurance information at the time of service and are appealing with medical records. The Plan denied your request. The Plan says that the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 inpatient hospital stay. Our reviewer says that these inpatient hospital services meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the enrollee could not have foreseen requiring these services prior to leaving the Plan's service area. The records show that the care provided was medically necessary. It would not have been medically reasonable to delay the services until the enrollee returned to the Plan's service area. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient hospital stay have been met. Therefore, we decided that the Plan has to pay for an inpatient hospital stay provided from May 30, 2019 to June 5, 2019.
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 providea Group 3 power wheelchair and accessories.You asked the Plan to providea Group 3 power wheelchair and accessories. You say that the current Group 2 power wheelchair no longer meets the enrollee's needs.The Plan denied your request. The Plan says the record does not show you can operate the requested power wheelchair safely.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating therequested PMD. The file does not showthat the enrolleecan safely operate the PMD being requested. The record shows the enrollee has had difficulty and safety issues operating the current Group 2 power wheelchair and there is no documentation the enrollee can safely and independently use a Group 3 power wheelchair. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to providea Group 3 power wheelchair and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
You asked the Plan to pre-approve the compression stockings. You say that these are medically necessary. The Plan denied your request. The Plan says that this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6533.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code G0483 provided on February 13, 2019.
You asked the Plan to pay for CPT code G0483. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the records do not support the billing of CPT code G0483.
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 G0483 is Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the record does not contain evidence that definitive testing on 22 or more drug classes was performed. Based on this information, we decided that Medicare rules for coverage of CPT code G0483 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code G0483 provided on February 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea pneumatic compression device (E0652) and segmentalappliance/sleeve (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeve. You say that the medical records provided will show proof of medical necessity.The Plan denied your request. The Plan says the enrollee has not have a failed four-week trial with E0650 or E0651. Therefore, E0667 is non-covered when requested in conjunction with the non-approved code E0652.
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 nothave to pre-approvea pneumatic compression device (E0652) and segmental appliance/sleeve (E0667)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower commode chair.You asked the Plan to pre-approvea shower commode chair. You say that a tilt in space chair is vital to clean her properly.The Plan denied your request. The Plan says that this is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pre-approvea shower commode chair.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on August 12, 2019.You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. 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 and the referring provider are not network providerswith the Plan. The Plan did not pre-approve the servicesat 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 physical therapy services provided on August 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEnbrel Sureclick for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not covered under 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 pre-approveEnbrel Sureclick for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerningany benefits and appeal rights.