Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tempus xT gene panel testing.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is 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 prostate cancer and lung cancer. It is not documented that you have decided to seek further cancer treatment, such as therapeutic chemotherapy. The Tempus xT panel is therefore 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 Tempus xT gene panel testing.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pulse oximeter purchased on to pay for a pulse oximeter purchased on June 24, 2020.

You asked the Plan to pay for a pulse oximeter purchased on this equipment. You say that your doctor recommended you purchase this item. The Plan denied your request. The Plan says this equipment is not covered by Medicare.

The Plan must follow Medicare rules. Medicare does not cover pulse oximeters as they are precautionary in nature. While this item may be helpful for you to use, it is not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a pulse oximeter purchased on to pay for a pulse oximeter purchased on June 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an advanced foot/rotational unit.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that an advanced foot feature is covered for K3 ambulator status. 

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 documentation states that the enrollee likes to go on long walks for exercise on uneven terrain He uses a wheelchair and standard walker in the home for ambulatory aids. The expected ambulation distance per day is 100 to 400 yards. The documentation does not support that the enrollee is a K3 ambulator, as requiring ambulatory aids is not consistent with K3 status. The requested K3 advanced foot and rotational unit are therefore 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 an advanced foot/rotational unit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care (99223) provided on December 17, 2020.

You asked the Plan to pay for initial hospital care. You say that these services were necessary and appropriate.
The Plan denied your request. The Plan says the documentation does not support that the 3 necessary key
components for coverage of this service have been met.

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 99223 is defined as Initial hospital care, per day, for the
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring
admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor
or unit.

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 initial hospital care. Our reviewer says that the elements of
the coverage criteria for CPT code 99223 are not satisfied in this case. Our reviewer found that the enrollee
underwent a medical evaluation on December 17, 2020. The submitted evaluation does not document the
necessary elements for high complexity medical decision making. The elements of the coverage criteria are not
met in this case, and the requested service cannot be recommended as billed.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does
not have to pay for initial hospital care (99223) provided on December 17, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient services provided from July 11, 2019, through July 16, 2019
with the reported secondary diagnosis E87.1, Hypo-osmolality and hyponatremia.

You asked the Plan to pay for inpatient services provided from July 11, 2019, through July 16, 2019 with the
reported secondary diagnosis E87.1, Hypo-osmolality and hyponatremia. You say that the medical records
support the reported secondary diagnosis of E87.1 for payment of DRG 032. The Plan denied your request. The
Plan says that the medical records do not support the reported secondary diagnosis of E87.1 for payment of
DRG 032.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with secondary diagnosis E87.1, Hypo-osmolality and
hyponatremia. 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 services provided
from July 11, 2019, through July 16, 2019 with the reported secondary diagnosis E87.1, Hypo-osmolality and
hyponatremia. Our reviewer says that the secondary diagnosis of hyponatremia is supported by the medical
records. Our physician reviewer found that the enrollee is a 76-year-old man with a history of a glioblastoma,
which had been resected as well as seizures, hypertension, and chronic hyponatremia. The enrollee developed
suspected hydrocephalus syndrome and was hospitalized on July 11, 2019 for placement of a
ventriculoperitoneal shunt. The enrollee's sodium was 132 prior to admission. On July 12, 2019 the enrollee
was having diarrhea. His sodium was 131.

Postoperatively the enrollee developed urinary retention, and a urinary catheter was placed on July 14, 2019.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient
services provided from July 11, 2019, through July 16, 2019 with the reported secondary diagnosis E87.1,
Hypo-osmolality and hyponatremia.

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 pre-approve a wig.

You asked the Plan to pre-approve a wig. You say that this request is necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 

In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pre-approve a wig.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the electromyography (EMG), nerve conduction studies, somatosensory testing, and intraoperative electroencephalogram (EEG) services providing along with intraoperative neuromonitoring coded as G0453 on January 27, 2021.

You asked the Plan to pay for the separately reported diagnostic testing. You say that these codes are all supported by the records and should be paid. The Plan denied your request. The Plan says these codes are not supported by the record.

The Plan must follow Medicare rules. Medicare rules say that services that are considered an integral part of other billed services are not separately payable. 

These additional services form an integral part of the IONM services provided on this date of service. Therefore, we decided that the Plan does not have to pay for the electromyography (EMG), nerve conduction studies, somatosensory testing, and intraoperative electroencephalogram (EEG) services providing along with intraoperative neuromonitoring coded as G0453 on January 27, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on March 18, 2021.

You asked the Plan to pay for non-emergency transportation, wheelchair van. The Plan denied your request. The Plan says wheelchair van transportation is not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services. 

The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for non-emergency transportation, wheelchair van provided on
March 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for transcutaneous electrical nerve stimulation (tens) device (E0730) electrodes, per pair (A4556) replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient (A4630) lead wires, per pair (A4557) provided on March 17, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the TENS device and supplies. You say that the cost of the TENS unit should have been covered. You paid the device out of pocket at $250 and saved the Plan $744.98. Please reimburse 80% of the $250. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 had network providers available who could have provided 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 transcutaneous electrical nerve stimulation (tens) device (E0730) electrodes, per pair (A4556) replacement batteries, medically necessary, transcutaneous electrical stimulator, owned by patient (A4630) lead wires, per pair (A4557) provided on March 17, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to hold you harmless for an office visit (99214) provided on February 19, 2021, by an out-of-network provider.

You asked the Plan to hold you harmless for an office visit. You say that you suffered a heart attack while visiting family in another state and were unable to return home until the provider released you to travel. The Plan denied your request. The Plan says that services were provided by an out-of-network provider without prior authorization.

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 hold you harmless for an office visit. Our reviewer says that that the OOA services were urgent, medically necessary and reasonable. Our physician reviewer says that per the documentation, as of the date of service in question, your condition had not stabilized to the extent that you could travel home to re-establish care with an in-network cardiologist.

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 office visit have been met. Therefore, we decided that the Plan has to hold you harmless for an office visit (99214) provided on February 19, 2021, by an out-of-network provider.

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 pre-approve a seat lift chair.

You asked the Plan to pre-approve a seat lift chair. You say that this device is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. 

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for behavioral counseling services (G0473) provided on February 24, 2021.

You asked the Plan to pay for behavioral counseling services. You say that this was billed correctly. The Plan denied your request. The Plan says this is not a valid telehealth service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The use of a telecommunications system may substitute for an in-person encounter for professional consultations, office visits, office psychiatry services, and a limited number of other physician fee schedule (PFS) services. The various services and corresponding current procedure terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes are listed on the CMS website. 

We find that CPT code G0473 is not supported in the medical record. Specifically, this is not a valid telehealth service code. Based on this information, we decided that Medicare rules for coverage of behavioral counseling services have not been met. Therefore, we decided that the Plan does not have to pay for behavioral counseling services (G0473) provided on February 24, 2021.
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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for pneumonia, kidney insufficiency and surgical management of an enterocutaneous fistula. Your medical problems are stable.

There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 an expandable controller with harness and electronic connection for a power wheelchair (PWC).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that an expandable controller with harness and electronic connection are used to control multiple power options. 

We looked at the file and Medicare rules. The requested an expandable controller with harness and electronic connection are not needed to control the approved PWC power options. 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 an expandable controller with harness and electronic connection for a power wheelchair (PWC).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for management of a lumbar compression fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Myopro Motion G device (L8702).

You asked the Plan to pre-approve the Myopro Motion G device. You say that the device is medically
necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

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 Myopro Motion G device. Our
reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the record indicates that the enrollee had a stroke in 2013 with resultant right
upper extremity partial paralysis. The record does not contain any primary source medical records for
consideration. Without records, the request cannot be supported.

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 Myopro Motion G device have not been met. Therefore, we decided that the
Plan does not have to pre-approve a Myopro Motion G device (L8702).