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

We decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on October 11, 2020.

You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment panels.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. 

We looked at the file and the rules. The documentation provided does not indicate the results of the testing would be used to determine a specific diagnosis or treatment strategy. The testing services were requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive cardiovascular panel provided on October 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).
You asked the Plan to pre-approve the wheelchair power seat elevation system. You say that this requested item is medically necessary. The Plan denied your request. The Plan says this item is non-covered.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is statutorily non-covered. We looked at the file and Medicare rules. In this case, the requested power seat elevation feature is statutorily non-covered. Based on this information, we decided that Medicare rules for coverage of the wheelchair power seat elevation system have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair power seat elevation system (E2300).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of the continuous positive airway pressure (CPAP) device.

You asked the Plan to pre-approve continued coverage of the CPAP device. You say that the CPAP device continues to be medically necessary. The Plan denied your request. The Plan says the enrollee is non complaint with using the CPAP device.

The Plan must follow Medicare rules. Medicare rules say that adherence to therapy for continued coverage of a CPAP device is defined as 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 

We looked at the file and Medicare rules. In this case, the submitted compliance reports indicate that the enrollee is non-compliant with CPAP use. Based on this information, we decided that Medicare rules for coverage of continued coverage of the CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of the continuous positive airway pressure (CPAP) device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.

You asked the Plan to pre-approve the device. You say that this si medically necessary. The Plan denied your request. The Plan says there is no objective documentation of a current or previous four-week trial of conservative therapy.

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 items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support a diagnosis of persistent chronic and severe lymphedema. There is no documentation to support the presence of edema in the clinician's note except a diagnosis of lymphedema. There are no skin lesions. There is no documentation found of a failure of a four week trial of conservative therapy. 

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 a pneumatic compression device for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).

You asked the Plan to pre-approve the admission. 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. 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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found there are no documented skilled nursing or skilled therapy needs. You are ambulating 100 feet, and tending to ADLs with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial, and as a practical matter, can be provided at a lower level of care. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on September 3, 2020 by an out of network (OON) provider.

You asked the Plan to pay for a specialist office visit. You say that you were unaware that you were not in-network with this specific plan. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating provider.

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 a specialist office visit provided on September 3, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance services (A0425, A0427) received February 21, 2021.

You asked the Plan to waive the deductible for the ambulance services. You say that you have never had to pay a deductible for ambulance services before. The Plan denied your request. The Plan says this claim processed entirely within your deductible.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for covered medical services, including Ambulance Services. 

The item or service you asked the Plan to waive the deductible for falls within the Ambulance Services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for Ambulance Services. This cost sharing is a contractual obligation that had not been met at the time the ambulance services was received on February 21, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance services (A0425, A0427) received February 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power operated vehicle (E1230) for the enrollee.

You asked the Plan to pre-approve the vehicle. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the guidelines have been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.

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 vehicle. Our reviewer says that the requested item is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee does not have a personal mobility deficit that impairs participation in mobility related activities of daily living such as toileting, feeding, grooming and bathing in customary locations within the home. The durable medical equipment order simply states that the enrollee has difficulty maneuvering and difficulty ambulating distances with a walker. Besides the order itself, no medical records were provided.

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 vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a power operated vehicle (E1230) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for robotic surgical techniques (S2900) provided on March 9, 2021.

You asked the Plan to pay for robotic surgical techniques. You say that this should be covered. The Plan denied your request. The Plan says this was not billed with a valid code.

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 find that CPT code S2900 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of robotic surgical techniques have not been met. Therefore, we decided that the Plan does not have to pay for robotic surgical techniques (S2900) provided on March 9, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90837) provided on March 8 to March 15, 2021, by an out of network provider.

You asked the Plan to pay for psychotherapy services. You say that you have been treating the enrollee for over 7 years. The Plan denied your request. The Plan says rules for out of network care have not been met.

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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90837) provided on March 8 to March 15, 2021, by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider on March 5, 2021.

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 a 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 subsequent nursing facility care, per day (99309) rendered by the out of network (OON) provider on March 5, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151), the direct skilled nursing services of a registered nurse in the home health or hospice setting, each 15 minutes (G0299), the hospice or home health care provided in a patient's home/residence (Q5001), and the services of a clinical social worker in home health or hospice settings, each 15 minutes (G0155) rendered by the out of network (OON) provider from September 1, 2020, through September 22, 2020.

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes (G0151), the direct skilled nursing services of a registered nurse in the home health or hospice setting, each 15 minutes (G0299), the hospice or home health care provided in a patient's home/residence (Q5001), and the services of a clinical social worker in home health or hospice settings, each 15 minutes (G0155) rendered by the out of network (OON) provider from September 1, 2020, through September 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.

You asked the Plan to pre-approve a power scooter. You say that this request is medically necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that your condition can be improved by a walker, cane or manual wheelchair. There is no evidence that a manual wheelchair would not be just as effective as a power scooter for your condition. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens polarization and progressive lenses provided on April 9, 2021.

You asked the Plan to pay for the lens polarization and progressive lenses. You say that you paid half of the lens based on your policy and insurance should pay. The Plan denied your request. The Plan says the services are not covered benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan contract states enhancements are not covered through your vision allowance. 

We looked at the file and the Plan's rules. The rules state that enhancements are not covered. Based on this information, we decided that the Plan's rules for coverage of the lens polarization and progressive lenses have not been met. Therefore, we decided that the Plan does not have to pay for the lens polarization and progressive lenses provided on April 9, 2021.

Please note, The Plan confirmed with the provider that you were overcharged. Please contact the Plan with questions regarding reimbursement.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a venography with intravascular ultrasound, angioplasty, stenting, and sedation (78520, 78522, 3012, 37252, 37253, 76937, 99152, and 99153).
You asked the Plan to pre-approve a venography with intravascular ultrasound, angioplasty, stenting, and sedation. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 a venography with intravascular ultrasound, angioplasty, stenting, and sedation. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records show the patient does not have documented history of blood clot in either leg or does not describe problems with varicose veins of the scrotal area. The documentation does not provide any evidence or indication for such invasive testing/procedure. The patient was not noted to have failed other first line surgical options for his varicose veins. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a venography with intravascular ultrasound, angioplasty, stenting, and sedation have not been met. Specifically, indications for this more extensive procedure is not documented in the plan of care. This means the services are not medically necessary. Therefore, we decided that the Plan does not have to pre-approve a venography with intravascular ultrasound, angioplasty, stenting, and sedation (78520, 78522, 3012, 37252, 37253, 76937, 99152, and 99153).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted molecular pathology procedure (CPT code(s): 81479) and MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (CPT code 81291) provided to the enrollee on August 24, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the Medicare rules have not been 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 pay for the laboratory services. physician reviewer found the review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. 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 laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted molecular pathology procedure (CPT code(s): 81479) and MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) (CPT code 81291) provided to the enrollee on August 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (20939, 22854, 63091) provided October 22, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does 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 find that CPT codes 20939, 22854, & 63091 are not supported in the medical record. Specifically, the operative report does not include enough information to confirm bone aspiration was aspirated through separate skin or fascial incisions. Additionally, the operative report does not include enough documentation to confirm at least 50% of the bone was removed from the vertebral body. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (20939, 22854, 63091) provided October 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hyperbaric oxygen therapy 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 medical necessity for this therapy is not established based on the industry standards.

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 the enrollee is paraplegic and has a sacral pressure ulcer. Although an x-ray result is noted that the enrollee has chronic osteomyelitis, no report is submitted nor do the clinical notes indicate that the osteomyelitis and tat it is refractory to conventional medical and surgical treatment. The record does not indicate that the enrollee has nay other indication for the requested service. 

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 hyperbaric oxygen therapy for the enrollee.