Persius/hicric huggingface dataset:
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital admission for a planned spinal surgery.
You asked the Plan to pre-approve the inpatient admission. You say that the enrollee needs this inpatient surgery. The Plan denied your request. The Plan says the surgery has been approved but can be provided in the outpatient setting.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 inpatient admission. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met. Our physician reviewer found the enrollee is to undergo a procedure, which is not on the inpatient only list and is not expected to require two midnights of inpatient level care. There is no documentation of uncontrolled co-morbidities pre-procedure, which would clearly necessitate a prolonged (i.e. two midnight) stay. The enrollee should present for, undergo and be monitored following the procedure as an outpatient. Should complications arise which necessitate a two midnight stay, the enrollee can be converted to inpatient status at that time under the two-midnight rule. 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 inpatient admission have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital admission for a planned spinal surgery.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a grab bar.
You asked the Plan to pre-approve a grab bar. You say that you are not able to properly bathe in the shower and are in urgent need of the grab bars. You say that your spouse is unable to assist you and that you are extremely weak due to your battle with cancer. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because they are not primarily medical in nature. While a grab bar 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-approve a grab bar.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical dressing supplies coded as A6403, A6446 and A4452 provided on September 9, 2019.You asked the Plan to pay for the surgical dressing supplies. You say that according to Medicare guidelines this claim denied in error.The Plan denied your request. The Plan says these services are a part A benefit and is included in the skilled nursing facility PPS payment.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. You provided surgical dressings supplies to the enrollee while admitted in a skilled nursing facility.  Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. Therefore, the plan is not required to pay you separately for this claim.Therefore, we decided that the Plan does not have to pay forthe surgical dressing supplies coded as A6403, A6446 and A4452 provided on September 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214), and a microfluid analysis of tears (83851QW, 83861QWA) provided on September 26, 2019 by the out of network provider.
You asked the Plan to pay for an office visit, and a tear exam. You say that you are appealing your denied claim. You were told by the receptionist that they accepted your plan. The Plan denied your request. The Plan says it is important to know which providers are part of the network because you must use network providers to get you medical care and services. The only exceptions are emergencies, urgently needed services when the health system network is not available, out-of-area dialysis services, and cases in which the Plan authorizes use of out-of-network providers.
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 an office visit (99214), and a microfluid analysis of tears (83851QW, 83861QWA) provided on September 26, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a wrist-hand orthosis (L3916) provided to the enrollee on June 6, 2019.

You asked the Plan to pay for the orthoses. 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) and a wrist-hand orthosis (L3916) provided to the enrollee on June 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the consultation (D9310), the alveoloplasty (D7320) for the upper left and upper right quadrants, the excision of the benign lesions (D7412) for the lower left and lower right quadrants, the general anesthesia (D9222), and the additional general anesthesia (D9223) provided from March 28, 2019 to July 2, 2019.
You asked the Plan to reimburse you for the dental services. You say that you do not understand why the service are not considered to be medical. The Plan denied your request. The Plan says the dental services you received are not covered.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to reimburse you for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to reimburse you for the consultation (D9310), the alveoloplasty (D7320) for the upper left and upper right quadrants, the excision of the benign lesions (D7412) for the lower left and lower right quadrants, the general anesthesia (D9222), and the additional general anesthesia (D9223) provided from March 28, 2019 to July 2, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Coronary Computed Tomography Angiography (CCTA) with Calcium Scoring (76499, 71250).You asked the Plan to pre-approvethe CCTA with Calcium Scoring. You say that the CCTA is medically necessary.The Plan denied your request. The Plan says the service is not medically necessary at this time.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the CCTA with Calcium Scoring. Our reviewer says that coverage criteria is not met at this time. Our physician reviewer found the requested CCTA is not being used as an alternative to traditional stress testing. The Enrollee had a normal exercise electrocardiogram test. The results were not unclear.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 CCTA with Calcium Scoring have not been met.Therefore, we decided that the Plan does not have to pre-approveCoronary Computed Tomography Angiography (CCTA) with Calcium Scoring (76499, 71250).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and 2 garments for
pneumatic compressor (E0667).
You asked the Plan to pay for a pneumatic compression device and garments. You say that the medical records
will support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee
did not have a four week trial with either E0650 or E0651. E0667 is also 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 not have to pay for a pneumatic compression device
(E0652) and 2 garments for pneumatic compressor (E0667).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided October 16, 2018.You asked the Plan to pay forthe orthosis. You say that you are requesting reconsideration as you were not aware that this enrollee previously was prescribed a back brace by another provider.The Plan denied your request. The Plan says the enrollee received this same item on June 27, 2018. This is less than the 5 years which Medicare determines is the reasonable useful lifetime for the equipment.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 the enrollee had L0650 at the time the orthosis was received. L0650 serves the same purpose as the orthosis.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0650) provided on October 16, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the intraoral periapical x-rays (D0220 x2, D0230) provided on September 11, 2019.
You asked the Plan to pay for the panoramic x-ray (D0330) and the intraoral periapical x-rays (D0220 x2, D0230). You say that you were not informed that you would have to pay the entire cost for the x-rays. The Plan denied your request. The Plan says the services are not covered benefits.
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. Though the Plan offers a dental benefit in excess of Medicare coverage, the panoramic x-ray (D0330) and the intraoral periapical x-rays (D0220 x2, D0230) are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) and the intraoral periapical x-rays (D0220 x2, D0230) provided on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not have to pre-approve Nulojix (J0485) for home infusion.You asked the Plan to pre-approve Nulojix for home infusion. You say that the enrollee cannot be without therapy.The Plandenied your request. The Plansays the requested drug has not been shown to be safe for home use.The Plan follows Medicare rules. Medicare rules say that immunosuppressive drugs are covered only for the specific labeled indications and approval for marketing by the FDA. Parenteral belatacept (Nulojix) (J0485)is not proven to be safe when administered in the home setting and therefore will be denied as not medically necessary when provided in that setting.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Nulojix for home infusionhave not been met. Specifically, the record shows that Nulojixhas been requested for use in the home. This medication has not been proven to be safe when administered in the home setting and therefore is not medically necessaryunder Medicare rules. Therefore, we decided that the Plan does not have to pre-approveNulojix (J0485) for home infusion
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system, upgraded electronics, and power tilt and recline for a power wheelchair.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered. The rules say that upgraded electronics and power tilt and recline are covered when specific 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 pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a spinal cord injury resulting in lower extremity paraplegia. The documentation shows that you are approved for a retractable joystick mount. The records do not show that you would be unable to use the joystick or a switch to engage the electronic features on the approved wheelchair; therefore, the upgraded electronics are not medically necessary. The records do not show that you meet the criteria for the requested power tilt system. You have documented elbow strength that would allow for a weight shift to relieve pressure. There is no detailed neuromuscular exam, physical therapy, or physician records to support that the power tilt system is needed for functional weight shifting or intermittent catheterization. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system, upgraded electronics, and power tilt and recline for a power wheelchair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic supplies (A4253, A4259, A4256, A4235) provided August 11 to October 30, 2019.You asked the Plan to pay for the diabetic supplies. You say that the items were medically necessary.The Plan denied your request. The Plan says the claim did not include a 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 physician order and 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. There was no order number or order details provided.Therefore, we decided that the Plan does not have to pay for diabetic supplies (A4253, A4259, A4256, A4235) provided August 11 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on July 15, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 an office visit provided on July 15, 2019 by the out of network provider.
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 the enrollee needs the interdisciplinary
approach that would be provided in an LTACH. The Plan denied your request. The Plan says the enrollee's 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 enrollee is currently undergoing treatment at an acute care hospital (ACH)
following heart valve surgery. Post-operatively, the enrollee developed respiratory failure and renal failure. She
was intubated/ventilated and started on hemodialysis. The enrollee eventually received a tracheotomy and has
recently been tolerating tracheotomy collar trials. As LTACHs and ACHs are licensed to provide the same
level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the
current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to
a lower level of care for any ongoing long term care needs.
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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee presented to the emergency department on 1/15/20 with pain between shoulder blades intermittently for 10 days; also noted bilateral lower extremity swelling with orthopnea and 15 pound weight gain in last few weeks. He was admitted to acute care for concerns of NSTEMI and for further workup and treatment. Based on the documentation provided, 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.