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

We decided that the Plan does not have to pre-approve a wheelchair ramp for the enrollee.You asked the Plan to pre-approve the ramp. You say that this is medically necessary.The Plan denied your request. The Plan says this would be considered a convenience item, and not primarily medical in nature.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The rules say that for equipment to be covered, it must primarily serve a medical purpose.The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicarenor the Plan covers equipment for use outside the home.The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a wheelchair ramp for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.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 preapprove a pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a topical hyperbaric oxygen chamber.
You asked the Plan to pre-approve the chamber. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider the requested service to be medically necessary. Based on this information, we decided that Medicare rules for coverage of the chamber have not been met. Therefore, we decided that the Plan does not have to pre-approve a topical hyperbaric oxygen chamber.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forEmergency Room services (29125, 73090, 99285) provided August 20, 2016.You asked the Plan to pay forthe Emergency Room services. You say that you should not be liable for payment because the provider failed to submit the claim timely.The Plan denied your request. The Plan says the claim was submitted untimely and the plan should not be liable.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the Emergency Room services was not filed until May 8, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forEmergency Room services (29125, 73090, 99285) provided August 20, 2016.However,Medicare rules say an enrollee canonlybe held liable for applicable deductibles or copaymentsin cases where the provider failed to submit the claim to the plan in a timely fashion. For more information, contact Medicare at 1-800-MEDICARE (1-800-633-4227).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH).
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in the current inpatient hospital.
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. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following surgery for a perforated large bowel. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee is undergoing ventilator weaning and receiving rehabilitative services. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long-term care needs. 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 admission to a long-term acute care hospital (LTACH).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that you need the requested orthotics because you cannot walk and are having severe pain. You say that you cannot put pressure on your heel.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion therapy services (S9500).You asked the Plan to pre-approve home infusion therapy services (S9500). You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says home infusion therapy services are not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. In this case, CPT code S9500 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Furthermore, Medicare says that home infusion services and supplies may be covered under a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.Therefore, we decided that the Plan does not have to pre-approve home infusion therapy services (S9500).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says face-to-face visits with the rehab physician at least three days per week are not required.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 enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to be able to perform fifteen hours per week of rehabilitative services with regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says the continued need for skilled care is not documented.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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee or thosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 13, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that  The Plan denied your request. The Plan says the services can be received from the network 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 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 an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig 70mg/ml autoinjector. You asked the Plan to pre-approve Aimovig. You say that the drug is medically necessary. The Plan denied your request. The Plan says this type of drug is not eligible for coverage under the Part B medical benefit. The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Aimovig 70mg/ml autoinjector.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea transthoracic echocardiography.You asked the Plan to pre-approvethe requested testing. The Plan denied your request. The Plan says the enrollee has no symptoms, or new or worsening findings.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 requested testing. Our physician reviewer found that the enrollee has a history of hypertension, hyperlipidemia, peripheral arterial disease and coronary disease including stent placement. A regadenoson nuclear stress test was reported to be normal in with no ischemia and normal left ventricular ejection fraction. A clinic note documents no chest pain or dyspnea. The enrollee has known coronary disease, but no documented recent cardiac symptoms, no documented moderate or greater valve disease, and no ischemia and normal left ventricular ejection fraction on recent nuclear stress testing. In this circumstance, the records do not support the medical necessity for echocardiography, as there are no documented covered indications for the procedure.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 requested testing have not been met. Therefore, we decided that the Plan does not have to pre-approvea transthoracic echocardiography.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on November 6, 2019.
You asked the Plan to pay for the surgical pathology. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says these services were provided in the global period.
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 88305 is Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy U reter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy.
We find that CPT code 88305 is not supported in the medical record. Specifically, it is inappropriate to report a procedure both as a global service and as the technical or professional components. Only the global services are allowed. Based on this information, we decided that Medicare rules for coverage of the surgical pathology have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs to be transferred to an LTACH level of care for a continuation of care for complex medical needs that require ongoing acute services. You say that the clinical information provided supports the need for LTACH services. The Plan denied your request. The Plan says the enrollee's medical condition is stable and he does not require the requested level of care.
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. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH). The enrollee has been treated for a bowel obstruction, PEA arrest and GI bleed. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency services (CPT 12011) provided to the enrollee on July 25, 2019.
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 Current Procedural Terminology (CPT) code 12011 (1 unit) remains 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 12011 is "simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less." 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found the documentation submitted was reviewed, and does not support service billed, in regards to body area that was repaired. A more appropriate CPT code is available for service 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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency services (CPT 12011) provided to the enrollee on July 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on December 12, 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 procedure code 64636 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 64636 is destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure). We find that CPT code 64636 is not supported in the medical record. Specifically, the operative report does not include documentation of destruction by neurolytic agent with imaging guidance of facet joint nerves. 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 pain management services rendered on December 12, 2019.