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

We decided that the Plan does not have to pre-approve a shower chair.

You asked the Plan to pre-approve a shower chair. You say that you have fallen three times and need this for prevention. The Plan denied your request. The Plan says this item is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. 

While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (Perfect Sleep Chair).

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there has been no order received from the provider for this chair.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are 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 pre-approve the services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no clear documentation that the seat lift is included in the treating practitioner's course of treatment. There is no clear documentation that the seat lift is likely to effect improvement in your condition or arrest or retard deterioration in your condition. There is no documentation that you are completely incapable of standing from a chair in the home.

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (Perfect Sleep Chair).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).

You asked the Plan to pre-approve this item. You say that a seat lift mechanism is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this item.

The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Specifically, the certificate of medical necessity issued by the provider does not indicate that you are completely unable to stand up from a regular armchair or any chair in your home. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of care with the out-of-network wound care specialist.

You asked the Plan to pre-approve the continuation of care with the out-of-network wound care specialist. You say that the requested continuation of care with the out-of-network wound care specialist is medically necessary. The Plan denied your request. The Plan says the requested continuation of care with the out-of-network wound care specialist is not medically necessary as there are in-network providers that can treat the enrollee.

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 

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 continuation of care with the out-of-network wound care specialist. Our reviewer says that the requested continuation of care with the out-of-network wound care specialist is not medically necessary. Our physician reviewer found there is nothing provided in the medical record to support a unique clinical circumstance or the need for the enrollee to continue with out of network care. The enrollee can be transitioned to in-network general surgery specialist. The enrollee has chronic lower extremity wounds and pyoderma. The Plan has two providers that are comfortable with this condition within the network. It is reasonable and medically standard to be evaluated by an in-network provider 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 continuation of care with the out-of-network wound care specialist have not been met. Therefore, we decided that the Plan does not have to pre-approve the continuation of care with the out-of-network wound care specialist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).

You asked the Plan to pre-approve these services. You say that finger stick testing is painful. The Plan denied your request. The Plan says you do not meet the criteria for coverage.

The Plan must follow Medicare rules. The rules say that a therapeutic CGM is covered when specific criteria are met. 

We looked at the file and Medicare rules. The records show that you are not currently treated with three or more daily injections of insulin. 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 pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the upper endoscopy procedure (43239).

You asked the Plan to waive the copayment for the endoscopy procedure. You say that you were told you would have no cost-share responsibility for a colonoscopy. The Plan denied your request. The Plan says the colonoscopy has been provided with no copayment required. However, the upper endoscopy is considered a surgical procedure and is subject to a $325 copayment unless it includes removal of polyps during a colorectal cancer screening. This service was provided as part of a screening but did not include removal of polyps.

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 $325 copayment for outpatient surgical procedures.

You have been asked to pay a $325 copayment for the endoscopy procedure. This specific endoscopy did not include polyp removal, which means it does not qualify for a 0$ copayment even when provided during a colorectal screening service. Therefore, this endoscopy procedure (43239) falls within the outpatient surgical procedures benefit category and is subject to a $325 copayment. 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 upper endoscopy procedure (43239).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

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 billed incorrectly.

The Plan must follow Medicare rules. Medicare rules say that inpatient services must be billed with POS code 21.

We looked at the file and Medicare rules. The file shows that the claim was billed with POS code 22 for an outpatient hospital; however, the enrollee was under inpatient status for the date of service at issue and should have been billed as POS code 21. 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 for the services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD) (0275T).

You asked the Plan to pre-approve this service. You say that this procedure is medically necessary due to medication not being effective in the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this procedure as you are not enrolled in a clinical study.

The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act) through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study that meets additional criteria. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, Medicare rules say that this service is covered when provided in a clinical study. The documentation provided does not indicate that you are enrolled in a clinical study at this time. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (PILD) (0275T).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed with side rails (E0265).

You asked the Plan to pre-approve this item. You say that an electric hospital bed is medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit under the enrollee's contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate for the enrollee in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed with side rails (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is no advantage in moving the member from the current acute care hospital to an LTACH.

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 and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. 

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 Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 76604 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 76604 is ultrasound, chest (includes mediastinum), real time with image documentation. 

We find that CPT code 76604 is not supported in the medical record. Specifically, there is no documentation of a chest ultrasound with real time image documentation. 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 for the ultrasound.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #2.

You asked the Plan to pre-approve the crown. The Plan denied your request. The Plan says the crown benefit has a limit to two per calendar year. The Plan also says that this request plus the enrollee's history has gone over this limit.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, crowns are limited to 2 per calendar year. The record shows that the enrollee received crowns and the enrollee's crowns benefit for the 2020 plan year had been exhausted. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #2.

Please Note: This denial was based off of the enrollee's 2020 Plan year benefits. Please check with the enrollee's 2021 Plan year benefits, and if coverage is available, you may submit a new appeal for pre-approval.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided by a non-participating provider.

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 services were rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided by a non-participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit.

You asked the Plan to pay for physician visit. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the enrollee was enrolled in hospice on this date of service and therefore the Plan is not responsible for payment.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for a physician visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for neurophysiology services 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 the billed place of service (POS) 15 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 the denied codes is:

CPT 95861:

Needle electromyography

Needle measurement and recording of electrical activity of cranial nerve-supplied muscles on both sides of body

CPT 95938:

Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system

CPT 95939:

Central motor evoked potential study (transcranial motor stimulation)

CPT 95955:

Special EEG Tests

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 CPT codes 95861 TC, 95868 TC, 95939 TC, 95939 TC, and 95955 TC were all billed with Place of Service 15. However, in the documentation submitted, it notes the enrollee was in the hospital when these services were provided. These codes have a PC/TC Modifier Status = 1 Diagnostic Tests. The technical portion of these codes are not paid in Place of Service 21 (facility) as it is included in payment to the facility and not separately reimbursed.

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 neurophysiology services provided to the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services.

You asked the Plan to waive the copayment for ambulance services. You say that you are unhappy with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.

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 $250 copayment for ambulance services.

You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance 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 copayment for ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 43246 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 43246 is esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube.

We find that CPT code 43246 is not supported in the medical record. Specifically, there is no documentation of a flexible transoral esophagogastroduodenoscopy. 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 for the services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81286, 81404, 81406, 81407, 81408, 81479).

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this test is not covered.

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 81286, 81404, 81406, 81407, 81408, & 81479 are not supported in the medical record. Specifically, the rules state that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic patients with suspected or documented cardiovascular disease. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81286, 81404, 81406, 81407, 81408, 81479).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Trilogy ventilator.

You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says there is no high-quality literature showing an improvement in health outcomes with the use of Trilogy for your condition.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found you have morbid obesity, obstructive sleep apnea (OSA), and obesity hypoventilation syndrome (OHS), although CO2 retention is not documented in the record. You do not have COPD according to pulmonary function testing in 2017. You do not have neuromuscular disease or thoracic restrictive disease. A home ventilator is not medically necessary in the treatment of OSA and OHS. BiPAP is the preferred treatment. There is no evidence of BiPAP failure. The AVAPS-AE mode can be delivered via certain BiPAP devices, and it appears this has not been tried. Medicare does not cover a home ventilator when used as BiPAP. 

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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a Trilogy ventilator.