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

We decided that the Plan does not have to pay for knee orthosis (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeve (L2397) provided to the enrollee on August 19, 2019.
You asked the Plan to pay for the orthoses and sleeve. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the durable medical equipment is not 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 pay for the orthoses and sleeve. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeve ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. The is no documentation of knee pain or other knee concerns. There is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is no objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered. 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 orthoses and sleeve have not been met. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833), addition to lower extremity orthosis, knee control, condylar pad (L2810) and suspension sleeve (L2397) provided to the enrollee on August 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services (99309) provided by out of network (OON) provider on August 28, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial as the provider rendered medically necessary services to the member in good faith. The Plan denied your request. The Plan says the health plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented. There is an on-line Medicare site to verify eligibility. There is no network deficiency for these services and alternate network providers were found.
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 has network providers available who can provide 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 subsequent nursing facility care services (99309) provided by the out of network (OON) provider on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on August 27, 2019.
You asked the Plan to pay for the ABPM. You say that the service is medically necessary. 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 ABPM have not been met. The ambulatory blood pressure monitor (ABPM) is only covered for suspected white coat hypertension, and must be performed for at least 24 hours to meet coverage criteria. Suspected white coat hypertension is defined as 1. Office blood pressure >140/90 mm Hg on at least three separate clinic/office visits with two separate measurements made at each visit; 2. At least two documented blood pressure measurements taken outside the office which are <140/90mm
Hg; and 3. No evidence of end-organ damage. ABPM is not covered for any other uses. This would be included in the payment for the ambulance service. Therefore, we decided that the Plan does not have to pay for the ABPM (CPT Code A4670) provided to the enrollee on August 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a pneumatic compression device and appliances.
You asked the Plan to provide the Flexitouch pneumatic compression device (E0652) and appliances (E0667) (E0667). You say that the Flexitouch pneumatic compression device will meet the enrollee's needs. The Plan denied your request. The Plan says the enrollee did not complete a four week trial with a basic device.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to provide a pneumatic compression device and appliances.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on April 16, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure codes 64493, 64494, and 64495 are 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 64493 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level. The definition of code 64494 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure). The definition of code 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure).We find that CPT codes 64493, 64494, and 64495 are not supported in the medical record. Specifically, the submitted records do not contain a documented date of service for these codes. 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 forthe services rendered to the enrollee on April 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for F2 genetic testing (CPT 81240) provided to the enrollee on April 25, 2019.
You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this test is not considered clinically efficacious, and this testing is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that F2 gene testing is not considered medically necessary by Medicare. Medicare does not consider the denied testing to be medically necessary. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for F2 genetic testing (CPT 81240) provided to the enrollee on April 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided by on October 10, 2019.
You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says there is no valid referral for this service.
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 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 a domiciliary, rest home visit provided on October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe care is not complex enough, and care can be received in a lower level of care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee's current functional status does not require this on an intensive rehabilitation facility therapy program level 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 Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on September 25, 2019 by an out of network provider.
You asked the Plan to pay for the non-emergent ambulance services. You say that the service was medically necessary. The Plan denied your request. The Plan says you did not request 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 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. The Plan did not pre-approve the service 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 ambulance services provided on September 25, 2019 by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on September 30, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for lumbar-sacral orthosis (L0650) provided to the enrollee on September 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe handicap driving course services you received on August 9, 2019.You asked the Plan to pay forthe services. You say that you were referred for these services.The Plan denied your request. The Plan says the services are not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services thatare not medically necessary are not covered. We looked at the file and Medicare rules. The handicap driving services in question do not meet the definition of medical necessity. The services were not reasonable and necessary for the diagnosis or treatment of an illness or injury. 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 forthe handicap driving course services you received on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on June 5, 2019.
You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
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 orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested ankle/foot orthoses were medically reasonable and necessary for the enrollee in this case, according to the criteria established by the LCD. A physical examination of the ankles and feet would reasonably be required to adequately assess whether the coverage criteria were met. The documentation does not support that the ankle/foot orthoses were medically reasonable and necessary in this case, as there is no documentation of a physical examination of the ankles and feet. The extremity exam is limited to "Warm, well perfused, no edema." The documentation in the medical record does not support that the enrollee in this case required stabilization for medical reasons, and had the potential to benefit functionally. 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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (L1971) provided to the enrollee on June 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 14, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this service was billed correctly. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered on January 2, 2019 to January 30, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that the required route of administration modifiers for dialysis services are JA, JB and JE. We looked at the file and Medicare rules. The file shows that the services were not billed with a required modifier of JA, JB, or JE. Therefore, we decided that the Plan does not have to pay for the services rendered on January 2, 2019 to January 30, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the mental health services (90792) provided on August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for mental health services. You say that the Plan should pay for this service. The Plan denied your request. The Plan says this service was 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 has network providers available who can provide 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 mental health services (90792) provided on August 15, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 2, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says criteria for the orthosis was not 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 lumbar-sacral orthosis (L0650). Our physician reviewer found the enrollee's chief complaint was back pain, as well as right knee pain documented in a separate note on the same day. The available documentation in the case file does not support that the requested lumbar-sacral orthosis was medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. An appropriate history and a physical examination of the back would reasonably be required to adequately assess whether the coverage criteria for an LSO have been met. The documentation does not support that the lumbar-sacral orthosis was prescribed for one or more of the covered indications in this case, as there is no documentation of a credible physical examination of the back. 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 lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 28, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this service was mandatory per hospital protocol. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule. The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of
"C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on August 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on September 10, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for knee orthosis (L1833) provided to the enrollee on September 10, 2019.