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

We decided that the Plan does not have to reimburse for tempurpedic mattress purchased on July 31, 2019 from an out-of-network provider.You asked the Plan to reimburse for the tempurpedic mattress. You say that you had a prescription from an internal medicine doctor.The Plan denied your request. The Plan says you self-referred out-of-network. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to reimburse for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.According to your records the Plan provided you with a (E0260) semi-electric hospital bed on March 24, 2017. However, on July 12, 2017 you requested the Health Plan physician to write a prescription for a sleep number bed to take to your own company/vendor. Coverage is limited to the standard item of equipment that adequately meets your medical needs. The Plan decides whether to rent or purchase the equipment, and they select the vendor. The Plan provided you with a semi-electric hospital bed with mattress. The sleep number bed can be purchased from any local furniture store and does not require a prescription. The requested provider in this case isnot 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 reimburse for these items/services.Therefore, we decided that the Plan does not have to reimburse for tempurpedic mattress purchased on July 31, 2019 from an out-of-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis (L1833) and a static, prefabricated wrist
hand and finger orthosis (L3807) provided September 9, 2019.
You asked the Plan to pay for the orthoses. You say that the records should support the necessity of the services
in dispute. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the
service so that the Medicare coverage criteria has been met.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record shows that the Plan made several attempts to obtain the physician order and proof of delivery
documentation for the items at issue in this appeal. The record does not contain a valid deliver ticket and proof
of delivery for the supplies provided in this case. The delivery ticket submitted did not include the carrier's
tracking number, nor did the proof of delivery include an order number or details to corroborate the delivery
ticket submitted. Of note, the proof of delivery is not itemized to indicate the specific supplies. Therefore, we
decided that the Plan does not have to pay for the knee orthosis (L1833) and a static, prefabricated wrist hand
and finger orthosis (L3807) provided September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT Code K0801). You asked the Plan to pre-approve the POV. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says the Medicare rules have not been met. The Plan approved a regular scooter that is deemed appropriate for your medical condition.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 POV have not been met. Your weight does not qualify you for a heavy duty scooter. However, the Plan approved a regular scooter that is deemed appropriate for your medical condition.Therefore, we decided that the Plan does not have to pre-approvethe POV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT Code K0801).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for room and board services provided on August 1, 2019 through August 20, 2019.
You asked the Plan to pay for the room and board. You say that you would like reconsideration because these services should be covered by the Plan. The Plan denied your request. The Plan says the level of care for this service was not billed correctly.
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 the room and board services are not supported in the record. Specifically, the non-contract provider has billed and inappropriate revenue code for Skilled Nursing Facility level of care. Based on this information, we decided that Medicare rules for coverage of the room and board have not been met. Therefore, we decided that the Plan does not have to pay for room and board services provided on August 1, 2019 through August 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided to the enrollee from October
12, 2018 at 12:18pm through October 13, 2018.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied
your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient hospital care. Our physician
reviewer found the enrollee was hemodynamically stable and appropriate for ambulance transport with
monitoring to a Plan facility. All inpatient care provided after 12:18 pm on October 12, 2018 through 9:48 pm
on October 13, 2018 was not needed on an emergent basis. The review has determined that the treating
physician did not document (in the physician notes, on a form, or in an order) that the patient was not stable for
transfer on any dates of 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 inpatient hospital care have not been met. Therefore, we decided that the Plan
does not have to pay for inpatient hospital care provided to the enrollee from October 12, 2018 at 12:18pm
through October 13, 2018.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 28, 2019 through September 30, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says that the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 28, 2019 through September 30, 2019.
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: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedeep brain stimulation (DBS) treatment for epilepsy.You asked the Planto pre-approvethe DBS treatments. You say that it is felt that this is the only option left to control the enrollee's seizures.The Plandenied your request. The Plansaysthis is not proven safe and effective and cannot be covered by Medicare.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 DBS treatments. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 73-year-oldwoman with a diagnosis of Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, intractable, without status epilepticus. She has refractory seizures, consisting of LOC with staring and oral automatisms, lasting for about 2 minutes, occurring at least once a week. She averages 4 seizures per week. A vagal nerve stimulator was previously placed and then removed, as it never helped with her epilepsy. The available data in the medical literature are insufficient to make a conclusive statement regarding the benefits and risks of deep brain stimulation in the management of drug-resistant epilepsy.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 DBS treatments have not been met.Therefore, we decided that the Plandoes not haveto pre-approvedeep brain stimulation (DBS) treatment for epilepsy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (99354) provided on May 10, 2019.You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99354 is prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service). We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the psychotherapy services. Our reviewer says that CPT code 99354 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include necessary information to validate that Prolonged evaluation and management or psychotherapy service was performed on May 10, 2019. There is no documentation of total additional time spent above and beyond (greater than 30 minutes) the E&M performed during the same encounter.We looked at this coder's review, the file, and Medicare rules. Basedon this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for psychotherapy services (99354) provided on May 10, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvean upper endoscopy for the enrollee.You asked the Planto pre-approvethe endoscopy. You say that this is medically necessary.The Plandenied your request. The Plansaysthe documentation fails to indicate that the enrollee has had a colonoscopy.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 endoscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found no documentation of GI bleeding was provided. The records do not support that the required circumstances have been met.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 endoscopy have not been met.Therefore, we decided that the Plandoes not haveto pre-approvean upper endoscopy for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the records provided support the need for SNF care.The Plan denied your request. The Plan says SNF care 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 above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment for dates of service March 18 -March 25, 2020. The enrollee does not have complex wound care or other SNF level skilled nursing need for dates of service March 18 -March 25, 2020. This enrollee's functional status does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment for the dates of service March 18 -March 25, 2020. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" for dates of service March 18 -March 25, 2020. As a practical matter, this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting during March 18 -March 25, 2020. 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 SNF services have not been met.Therefore, we decided that thePlan does not have to pre-approveskilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve MRI of the pelvis for the enrollee.
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically reasonable or necessary. Our physician reviewer found the accepted criteria for MRI in prostate cancer include a rising PSA and/or physical findings of a mass etc. This patient had a Gleason score of 6 with low probability of diffuse or aggressive malignancy. The PSA level while elevated at 9.9 has remained stable since 2017. Had the PSA risen over time since 2017, criteria would have been met for MRI, however that is not the case in this individual. 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve MRI of the pelvis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to Orthopaedic Surgical Center, an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plan denied your request. The Plan says please continue to work with your Care Team to report any changes in your health status and for assistance in finding an in network facility where this procedure could be performed.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 referral to Orthopaedic Surgical Center, an out-of-network provider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the chest, abdomen and pelvis.
You asked the Plan to pre-approve the scan. You say that this is medically necessary due to battling two types of cancer. The Plan denied your request. The Plan says that this is not reasonable and not medically necessary.
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 medically reasonable and necessary. Our physician reviewer found the PET/CT of 3/6/20 revealed hypermetabolic areas in both lungs likely inflammatory in nature but she also has a biopsy proven upper lobe malignant process. While PET/CT is useful for lung analysis the prior PET scan report showed findings that also could be related to multifocal malignancy. Since therapeutic decisions depend on the nature of the previously described bilateral opacities detailed anatomic analysis not available on PET/CT would help in treatment decision making process. Also, the fact the liver has been abnormal on prior scans but the biopsy was inconclusive supports another look at the liver perhaps using multiphase post enhancement technique. Finally, in a patient with vulvar cancer a detailed look at the pelvic anatomy would be in order especially since your last CT was 1/21/20. You have multiple primary malignancies and as such surveillance is complicated as multiple therapeutic decisions hinge upon imaging findings/changes. For this reason CT of the chest, abdomen and pelvis should be approved. 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 been met. Therefore, we decided that the Plan has to pre-approve CT scan of the chest, abdomen and pelvis.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional CPAP mask.
You asked the Plan to pre-approve the additional mask. You say that this is medically necessary, as the current mask is painful. The Plan denied your request. The Plan says the plan would approve a request to see a specialist for the fitting of a comfort-related mask, as one mask is covered every three months.
The Plan must follow Medicare rules. Medicare rules say that one CPAP mask is covered every three months. An additional mask cannot be covered, as only one mask can be covered every three months. Based on this information, we decided that Medicare rules for coverage of the additional mask have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional CPAP mask.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysall services that would be provided in the LTACH are being provided already in the current acute care setting already approved.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable andnecessary in this case. Our physician reviewer found long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. In this case, ongoing care needs include surveillance laboratory studies, wound care, continued non-weight bearing status, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH thatare not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.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 LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.