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

We decided that the Plan does not have to pay for the hospital discharge services rendered to the enrollee on May 19, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99239 is not supported.
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 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 pay for the hospital discharge services rendered to the enrollee on May 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee no longer requires the daily skilled care of a professional therapist or licensed nurse.
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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 12, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you had your wellness visit and should not be charged a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for PCP office visits. You have been asked to pay a $5 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The medical record shows you were treated for Alzheimer's disease, lipid disorders, falls, and age-related physical debility, in addition to the wellness visit.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided by on September 12, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay forthe services rendered to the enrollee from December 2, 2014 to January 2, 2015.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says that the services were not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services were not medically necessary because you did not meet the inpatient criteria; however, there are no medical records in the submitted documentation. Without medical records, a determination based on medical necessity cannot be supported. Therefore, we decided that the Plan has to pay forthe services rendered to the enrollee from December 2, 2014 to January 2, 2015.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 toopen the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a vertebral corpectomy (63091) provided on July 1, 2019.
You asked the Plan to pay for the vertebral corpectomy. You say that you would like reconsideration based on the records submitted, The Plan denied your request. The Plan says the records submitted do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 63091 is vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the vertebral corpectomy. Our reviewer says that CPT code 63091 is not supported by the medical records submitted. Our reviewer found the operative report did not include documentation of a partial or complete vertebral corpectomy (vertebral body resection), using a transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; for each additional segment (Listed separately in addition to code for primary procedure).
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vertebral corpectomy have not been met. Therefore, we decided that the Plan does not have to pay for a vertebral corpectomy (63091) provided on July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe immediate upper denture (D5130) and the immediate lower denture (D5140) provided on May 16, 2018.You asked the Plan to pay forthe dental items. The Plan denied your request. The Plan says dentures are not listed as a covered service.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, dentures are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the immediate upper denture (D5130) and the immediate lower denture (D5140) provided on May 16, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care (99292), cardiopulmonary resuscitation (92950), tube thoracostomy (32551) and intubation (31500) provided on June 12, 2019.
You asked the Plan to pay for the critial care, cardiopulmonary resuscitation, tube thoracostomy and intubation. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records do not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the critial care, cardiopulmonary resuscitation, tube thoracostomy and intubation. Our reviewer says that CPT codes 99292, 92950, 32551 and 31500 do not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided include a critical care note dated for June 13, 2019, therefore, CPT codes 99292, 92950, 32551 and 31500 cannot be verified for the billed date of service June 12, 2019. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the critial care, cardiopulmonary resuscitation, tube thoracostomy and intubation have not been met. Therefore, we decided that the Plan does not have to pay for critical care (99292), cardiopulmonary resuscitation (92950), tube thoracostomy (32551) and intubation (31500) provided on June 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy test strips.

You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that there is no medical reason you can't use the preferred meter.

The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.

The items at issue are Prodigy test strips. Prodigy is not a preferred provider with the Plan for diabetic supplies. Therefore, we decided that the Plan does not have to pre-approve Prodigy test strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided September 9, 2019 to October 8, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says the 100 SNF day benefit has been exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from April 26, 2019 to September 8, 2019. The Plan has covered 100 days of SNF care. Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided September 9, 2019 to October 8, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve morphine sulfate extended-release tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare 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-approve morphine sulfate extended-release tablets.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevator, an expandable controller, harness, and electrical connection.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
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 accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee's power mobility device could not be repaired. As such, these accessories and requests are deemed 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevator, an expandable controller, harness, and electrical connection
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveheart monitoring to be provided by an out of network (OON) provider.You asked the Plan to pre-approvethe out of network heart monitoring. You say that you are the only provider who can supply the equipment being requested.The Plan denied your request. The Plan says the requested equipment can be provided in network. 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 provider at issue in this case is not a network provider with the Plan. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Planwas correct in denying the request to pre-approve the out of network heart monitoring. Our reviewer says that  Our physician reviewer found 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 out of network heart monitoring have not been met. 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 the out of network heart monitoring.Therefore, we decided that the Plan does not have to pre-approveheart monitoring to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) with manual calibration of each chamber coded as E0652.
You asked the Plan to pre-approve the E0652 PCD. You say that this is felt to be necessary for your condition. The Plan denied your request. The Plan says there is not sufficient evidence of a trial of an E0650 or E0651 device.
The Plan must follow Medicare rules. Medicare rules say that to qualify for coverage of an E0652 PCD, there must be a failure of a four-week trial of an E0650/E0651 device, including daily, multiple hour usage. In this case, the record only shows a single, less than one hour trial. This does not meet the requirements for coverage of the E0652 PCD. Therefore, we decided that the Plan does not have to pre-approve a segmented pneumatic compression device (PCD) with manual calibration of each chamber coded as E0652.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee used the brand. The Plan denied your request. The Plan says there is not medical reason you are medically unable to use the Plan preferred meter and test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve test strips.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nerve conduction studies provided on October 8, 2019.
You asked the Plan to waive the copayment for the nerve conduction studies. You say that you were not informed there would be a substantial copayment. You say that you should not be responsible. The Plan denied your request. The Plan says the copayment applied 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 a $275 copayment for all other diagnostic procedures and tests. You have been asked to pay $194.58, which is less than the standard $275 copayment for the nerve conduction studies. The nerve conduction studies fall within the "Outpatient diagnostic tests and therapeutic services and 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 copayment for the nerve conduction studies provided on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve reconstruction surgery of mandible implant for the enrollee.
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve reconstruction surgery of mandible implant for the enrollee.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to pre-approve Group 3 power wheelchair (K0861) and accessories/attachments (E1028, E2377, E2313, E1007, E2311, E2620, K0108). We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a Group 3 power wheelchair and accessories/attachments. You say that this is medically necessary. The Plan says that that a new power wheelchair is not necessary and that your previous wheelchair can be repaired.
We decided that the Plan has to pre-approve Group 3 power wheelchair (K0861) and accessories/ attachments (E1028, E2377, E2313, E1007, E2311, E2620, K0108).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided evidence that the enrollee's previous power wheelchair is less than five years old. Therefore, we decided that the Plan has to pre-approve Group 3 power wheelchair (K0861) and accessories/ attachments (E1028, E2377, E2313, E1007, E2311, E2620, K0108).
We also decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve .
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 25, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says to be able to price non-par, home health claims correctly in the CIS PRO system, the claim must be billed with a valid HIPPS (Health Insurance Prospective Payment System) code, a valid 18 digit alphanumeric Treatment Authorization Code, correct type of bill and a valid 5-digit CBSA (Computer Based Statistical Area) code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim includes an invalid type of bill. Type of Bill 0324 is not valid for this home health claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 3, 2019 to September 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cryo-ablation therapy.
You asked the Plan to pre-approve cryo-ablation therapy. You say that this service is medically necessary. The Plan denied your request. The Plan says peer-reviewed literature has not established the effectiveness of cryoablation therapy for the enrollee's condition.
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 cryotherapy with truFreeze. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the current literature supports possible advantage of radiofrequency ablation (RFA) over cryoablation in the enrollee's case -- e.g. he requires long-segment ablation and his dysplasia is high grade. As such, the medical necessity of cryo versus RFA is not apparent in his circumstance. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of cryotherapy with truFreeze have not been met. Therefore, we decided that the Plan does not have to pre-approve cryo-ablation therapy.