Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for LSO back brace (L0648), infarred wand (E0691) and endeaver wrist (L3916) provided on July 27, 2020.

You asked the Plan to pay for LSO back brace, infarred wand and endeaver wrist. You say that the items are medically necessary. The Plan denied your request. The Plan says insufficient documentation was submitted.

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 pay for LSO Back brace, infarred wand and endeaver wrist. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no physical examination of the back, wrist or skin documented to indicate the medical necessity of the items requested.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LSO Back brace, infarred wand and endeaver wrist have not been met. Specifically, the documentation submitted does not show the medical necessity of the items requested as there are no physical examinations. Therefore, we decided that the Plan does not have to pay for LSO back brace (L0648), infarred wand (E0691) and endeaver wrist (L3916) provided on July 27, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for extensive arthroscopic debridement (29823).

You asked the Plan to pay for extensive arthroscopic debridement. You say that this should be covered. The
Plan denied your request. The Plan says this code 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 29823 is arthroscopy, shoulder, surgical; debridement,
extensive.

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 extensive arthroscopic debridement. Our
reviewer says that this code is not supported. Our physician reviewer found for extensive debridement to be
valid, the documentation should clearly support that multiple soft tissue structures (labrum, subscapularis,
supraspinatus) or a chondroplasty of the humeral head or glenoid were debrided. The medical records do not
document what tissue was debrided. Without this information, this code cannot be verified.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of extensive arthroscopic debridement have not been met. Therefore, we decided
that the Plan does not have to pay for extensive arthroscopic debridement (29823).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the Laryngoscopy (31579).

You asked the Plan to waive the copayment for the Laryngoscopy. You say that you do not believe your service should be charged a surgery copayment. The Plan denied your request. The Plan says the copayment was 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 $150 copayment for each visit to a hospital outpatient surgical department.

You have been asked to pay a $150 copayment for the Laryngoscopy. This service falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 Laryngoscopy (31579).
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 records provided support the need for IRF care.
The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The
Plan says that the enrollee can safely receive the services needed in another setting.

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. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee is
living in a custodial nursing facility. She has ongoing weakness and trouble ambulating. The enrollee's medical
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be
provided in a different level of care. There is not a reasonable expectation that the enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or therapy services on a daily basis. This 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammogram provided by an out-of-network provider.

You asked the Plan to pay for the mammogram. You say that the doctor told you to go to this location to get the mammogram. The Plan denied your request. The Plan says the services were not authorized.

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 the mammogram provided by an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L0650 and L3916) provided to the enrollee.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says there is evidence of misrepresented services.

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 the denied codes is:

HCPCS L0650:

Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior
extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s),
produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include
padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf.

HCPCS L3916:

Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft
interface, straps, prefabricated, off-the-shelf.

We asked our coding 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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our coding reviewer found it cannot be
verified that was the equipment billed was actually sent to the enrollee. A delivery ticket and shipping receipt
should match up to confirm medical equipment was delivered to the enrollee.

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 services have not been met. Therefore, we decided that the Plan does not
have to pay for orthoses (L0650 and L3916) provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for telehealth services.

You asked the Plan to waive the copayments for the telehealth services. You say that you did not sign up for telehealth services. The Plan denied your request. The Plan says telehealth services were billed, and you were charged this copayment 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 $10 copayment for Physician Services.

You have been asked to pay a $10 copayment for the telehealth services. The telehealth services fall within the Physician Services 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 copayments for telehealth services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection.

You asked the Plan to pre-approve Botox. The Plan denied your request. The Plan says this is not medically
necessary.

The Plan follows Medicare rules. Medicare rules say that Botox is coverage for the indications established in
the applicable LCD.

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 Botox. Our reviewer says that the
requested Botox injection is not medically reasonable and necessary. Our physician reviewer found that there is
no documentation that this member improved after Botox. The requested injection is not medically reasonable
or necessary according to the coverage criteria established in the LCD.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to
pre-approve a Botox injection.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee.

You asked the Plan to pay for this claim. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

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 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 physician services provided to the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services.

You asked the Plan to pay for the acupuncture services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.

We looked at the file and Medicare rules. Review of the file shows that the services rendered were provided by a licensed acupuncturist and not a physician. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, these services are only covered when provided by a physician licensed to do acupuncture. Therefore, we decided that the Plan does not have to pay for the acupuncture 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 you would like reconsideration because admission is necessary for continued medical management and therapies. The Plan denied your request. The Plan says Medicare criteria for admission are not met.

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. Our physician reviewer found there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for an ambulance response without transportation (A0998).

You asked the Plan to pay for an ambulance response without transportation. You say that you are being charged too much because the ambulance didn't do anything. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.

The ambulance company did not provide transport services. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for an ambulance response without transportation (A0998).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for CMT; spinal, 3-4 regions (CPT code 98941-59) and CMT; extraspinal, 1 or more regions (CPT Code 98943-59).

You asked the Plan to pay for the services. You say that you called previously and were advised that you would only have a $20 copayment for all Medicare-covered chiropractic services. The Plan denied your request. The Plan says the services billed on this claim are not covered as billed, according to the terms of the health plan and Medicare rules. The Plan states the claim was correctly denied as non-covered and the provider has been notified of Medicare's guidelines for billing chiropractic services.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 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. The rules say that a chiropractor must place an 'AT' modifier on a claim when providing active/corrective treatment to treat subluxation. The plan has made the provider aware of this requirement and advised them that if appropriate, a corrected claim is required to include the 'AT' modifier before this service can be covered. We looked at 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 pay for CMT; spinal, 3-4 regions (CPT code 98941-59) and CMT; extraspinal, 1 or more regions (CPT Code 98943-59).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679).

You asked the Plan to pre-approve percutaneous implantation of neurostimulator electrode array and implantable neurostimulator. 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 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 percutaneous implantation of neurostimulator electrode array and implantable neurostimulator. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there was no indication of psychological screening nor was there documentation of multidisciplinary treatment.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array and implantable neurostimulator have not been met. Specifically, the enrollee does not meet the criteria for the services requested. This means the services are not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) (64555) and implantable neurostimulator, pulse generator, any type (L8679).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onpattro.

You asked the Plan to pre-approve Onpattro. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Onpattro. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Onpattro is medically reasonable and necessary or safe and effective for the enrollee in combination with tafamidis. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onpattro have not been met. Therefore, we decided that the Plan does not have to pre-approve Onpattro.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

The Plan must follow Medicare rules. The rules say that 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. Our physician reviewer found based on the medical records provided the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case.

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 IRF admission and services.