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

We decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve office visits to be rendered by the out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system (E2300).
You asked the Plan to pre-approve the seat elevator. You say that you are requesting approval of replacement of your electric wheelchair. Your need the controller system to be able to move the electronic wheelchair. Your hands are not mobile. The Plan denied your request. The Plan says a seat elevator does not serve a primary medical purpose and is statutorily non-covered.
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. Based on this information, we decided that Medicare rules for coverage of the seat elevator have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair accessory, power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you cannot get out of bed or walk without falling. The Plan denied your request. The Plan says this item is not a covered benefit.
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-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87635) provided March 1, 2021.
You asked the Plan to pay for the lab services. You say that the testing was necessary to return from travelling or you could be fined. The Plan denied your request. The Plan says tests not ordered by a physician are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary. We looked at the file and Medicare rules. The testing performed was performed for travel purposes and it was not a medically necessary test ordered by a treating physician. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (87635) provided March 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the crutch substitute (E0188).

You asked the Plan to pre-approve the crutch substitute. You say that you have a fractured ankle and is not able to stand upon crutches. You have no one around to help you and you need the scooter to get around the house. The Plan denied your request. The Plan says crutch substitutes such as knee walkers have not been proven to be safe and effective.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at this the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the crutch substitute have not been met. Therefore, we decided that the Plan does not have to pre-approve the crutch substitute (E0188).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve specialist services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you would like approval for these services. The Plan denied your request. The Plan says there is no network deficiency of providers available for these services.
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 specialist services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says the efficacy of this device has not been established.
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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of thorax/abdomen/pelvis without contrast for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary per the NCD guidelines.
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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found the records indicate that the enrollee has had unexplained weight loss. The record does not include any laboratory or initial testing results. The record does not establish the medically necessary or reasonableness, as defined by Medicare rules, of the requested services for the enrollee's clinical scenario.
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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of thorax/abdomen/pelvis without contrast for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you have multiple sclerosis and unable to stand
for long because your dizzy. The Plan denied your request. The Plan says this item is not a covered benefit.
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-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like approval for this equipment to be provided out-of-network. The Plan denied your request. The Plan says there are in-network providers available for this equipment.

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 portable oxygen concentrator 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 portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that you need this to drive and travel. The Plan denied your request. The Plan says this is not covered only for use with travel.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) for the initial and boost phases for the enrollee.
You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says only weekly picture studies are needed.
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 therapy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found routine use of IGRT is not within the accepted standards of care. No rationale for IGRT was provided in the case records. Without a plausible rationale for the need for this request, this cannot be seen as "furnished in accordance with accepted standards 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 the therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve image-guided radiation therapy (IGRT) for the initial and boost phases for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuous glucose monitoring system (CGM).

You asked the Plan to pre-approve the CGM. You say that the CGM is necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. 

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve continuous glucose monitoring system (CGM).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve continued inpatient hospital care after August 27, 2021.

You asked the Plan to pre-approve continued inpatient care. You say that the treating physician does not agree with discharge to a lower level of care because the enrollee would be highly likely to be readmitted to the hospital. The Plan denied your request. The Plan says that ongoing care in the LTACH is not medically necessary.

The Plan must follow Medicare rules. Before discharging an enrollee from an inpatient hospital level of care, Medicare rules say that the Plan must obtain concurrence from the physician who is responsible for the enrollee's inpatient care. 

In this case, the record does not show that the physician responsible for the enrollee's inpatient care concurs with this discharge. Therefore, we decided that the Plan has to pre-approve continued inpatient hospital care after August 27, 2021.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ventilation management services rendered on April 6, 2021.
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 94002 is not payable.
The rules say that, for edits with a modifier indicator of 0, the Column 2 code is not payable.
The provider submitted a claim for procedure codes 99284 (emergency room services) and 94002 (ventilation management services). Code 94002 is a column II code with a modifier indicator of 0 when billed with column I code 99284. Code 94002 is not separately payable. Therefore, we decided that the Plan does not have to pay for the ventilation management services rendered on April 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on May 20, 2021.
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 70544 is not separately payable.
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70544 (MRA head) and 70551 (magnetic resonance imaging of the brain stem). Code 70544 is a column II code with a modifier indicator of 1 when billed with column I code 70551. Code 70544 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the magnetic resonance angiography (MRA) of the head rendered on May 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on March 17, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled code and is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on March 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the arthrodesis procedure you had at an
outpatient hospital facility from March 10, 2021, to March 11, 2021, and the physical therapy evaluation you
had on March 11, 2021.

You asked the Plan to reduce the copayments for the arthrodesis procedure and the physical therapy evaluation.
You say that you are on Social Security disability and cannot afford these charges. You stated that you believe
your copayment should be $250. The Plan denied your request. The Plan says it has paid for the self-administered
drugs, so that issue is not part of this appeal. The Plan also stated that you were charged these
copayments correctly for the remaining services.

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 $335
copayment for surgery at an outpatient hospital facility and a $35 copayment for physical therapy services.

You have been asked to pay a $335 copayment for the arthrodesis procedure and a $35 copayment for the
physical therapy evaluation. 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 reduce the copayments for the arthrodesis procedure
you had at an outpatient hospital facility from March 10, 2021, to March 11, 2021, and the physical therapy
evaluation you had on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (87086) rendered by the out-of-network (OON) provider on October 21, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service 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 this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (87086) rendered by the out-of-network (OON) provider on October 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment and documentation, with a finding of high risk (D0603) provided October 29, 2019.
You asked the Plan to pay for the caries risk assessment. You say that you would like this service covered. The Plan denied your request. The Plan says this service is not covered under your 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the caries risk assessment and documentation, with a finding of high risk (D0603) provided October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (CPT code 90832) provided to the enrollee on February 11, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. There was no documented contact with the attending/primary care physician. Medicare payment for clinical psychologist's services is limited to treatment by practitioners with a Psychology Doctoral degree, Licensed or certified in the State, with enrollee consent, and consult with the attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy (CPT code 90832) provided to the enrollee on February 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.

You asked the Plan to pre-approve Vertiflex Superion device placement surgery. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have 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 Vertiflex Superion device placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you have chronic low back pain and lumbar spinal stenosis with neurogenic claudication. The record indicates that imaging has demonstrated multi-level disease with both spinal and neuroforaminal stenosis. The central stenosis is not quantified. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex Superion device placement surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve Vertiflex Superion device placement surgery.