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

We decided that the Plan does not have to pay for an office visit and orthotics services (CPT 99213, CPT 99072, HCPCS L3020) provided to the enrollee on September 24, 2020.
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 services were not processed 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. In this case, the CPT Code Manual definition of the denied codes is: CPT 99213: Evaluation and management of an established patient in an office or outpatient location for 15 minutes HCPCS L3020: Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each CPT 99072: Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease 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 99213 was previously reimbursed under claim 820202980065582, so no additional payment would be due. HCPCS L3020-LT is not reimbursable when billed under place of service 11. CPT 99072 has a status of "Bundled" and is included in payment for the 99213 for the same date, therefore no additional payment is allowed.
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 an office visit and orthotics services (CPT 99213, CPT 99072, HCPCS L3020) provided to the enrollee on September 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair transit option.

You asked the Plan to pre-approve a power wheelchair transit option (K0108). You say that the enrollee needs a Group 3 power wheelchair and accessories. The Plan denied your request. The Plan says the transit option is statutorily not covered by Medicare.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home.

The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair transit option.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CGM system (CPT code E1399), for the enrollee.

You asked the Plan to pre-approve the CGM. You say that the enrollee has been holding off on using insulin because they have been managing their blood glucose level with the Dexcom 6. You state without the CGM it is almost guaranteed that the enrollee will be on daily insulin therapy and possibly other short acting insulins. The Plan denied your request. The Plan says the Medicare rules have not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Additionally, the incorrect code was submitted. Therefore, we decided that the Plan does not have to pre-approve a CGM system (CPT code E1399), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography (CPT code 93307), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says no current office data was provided for review.

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 service. Our physician reviewer found due to the patient being asymptomatic and this being a screening test, the patient does not meet the criteria laid out in the LCD.

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography (CPT code 93307), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure
(CPAP) device.
You asked the Plan to pre-approve CPAP replacement. You say that you are experiencing severe shocks from
this equipment and you will only accept complete replacement. The Plan denied your request. The Plan says
the denial of authorization for this item is correct, because Medicare does not cover replacement of DME
within the reasonable useful lifetime and your CPAP device could be evaluated for repairs with a machine lent
to you.
The Plan must follow Medicare rules. Medicare rules say that while Medicare does cover repairs to DME
items, it does not cover replacement of a DME item within the reasonable useful lifetime of the equipment
which is no less than 5 years.
We looked at the file and Medicare rules. You say that you obtained this CPAP machine approximately 3 years
ago. Therefore, this equipment has not reached its reasonable useful lifetime and is not eligible for replacement
at this time. Based on this information, we decided that Medicare rules for coverage of CPAP replacement have
not been met. Please contact the Plan for more information about having your equipment evaluated for repair.
Therefore, we decided that the Plan does not have to pre-approve a replacement continuous positive airway
pressure (CPAP) device.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the sacroiliac joint infusion.
You asked the Plan to pre-approve the pelvic surgery. You say that you would like reconsideration because the
requested procedure is medically necessary. The Plan denied your request. The Plan says you have not failed
non-surgical treatment, do not have pictures to show nerve is being squeezed, major new problems with
strength, bone loss in spine or problems with prior surgery.
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 pelvic surgery. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found there is no documentation of adequate conservative measures to include physical
therapy.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the pelvic surgery have not been met. Therefore, we decided that the Plan does
not have to pre-approve the sacroiliac joint infusion.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed.

You asked the Plan to pre-approve the requested hospital bed. You say that you need the bed elevated, and your position changed. The Plan denied your request. The Plan says the request for the bed is not supported by the physical therapy notes.

The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed is only covered under certain medical indications.

We looked at the file, and Medicare rules. The records show that you demonstrate improved independence in bed mobility, transfers, and functional activities. There is no indication that you require frequent body changes, or changes in position that are not feasible in an ordinary bed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve the additional trips. You say that this is medically necessary. The Plan
denied your request. The Plan says this exceeds the benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case. The Plan covers a maximum of 40 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that with this request, you will have exhausted the Plan maximum benefit for coverage of routine
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.

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 this is not medically necessary.

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 there is no documentation provided necessitating admission to a LTACH. 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. There are no
services available at the LTACH that the enrollee requires that are not available at the health care setting being
offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only
on an inpatient basis.

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 LTACH for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. There is no documentation that the patient requires the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 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 IRF admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl patches.

You asked the Plan to pre-approve Fentanyl patches. You say that the enrollee has failed other medications. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Fentanyl patches.

Benefits for Fentanyl patches may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (95810).
You asked the Plan to pre-approve polysomnography. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Split-Night Studies are covered when specific criteria 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 polysomnography. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested code 95810 duplicates the diagnostic portion of the approved sleep study with pressure titration. The review has determined that the enrollee does not meet the coverage criteria. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (95810).
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 exceeds the criteria for a LTACH admission. The Plan denied your request. The Plan says admission to a LTACH is not medically necessary.
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 there is no documentation provided necessitating admission to a LTACH. 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 he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan denied your request. The Plan says you do not meet criteria for coverage of an IRF admission.
The Plan must follow Medicare rules. The rules say that an IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You require physical and occupational therapy services; however, you do not require an intensive inpatient rehabilitation therapy program. Additionally, there is no documentation provided that indicates you require an intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care in the home with home health services or at the skilled nursing facility level appears to be appropriate in this case. 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 an acute inpatient rehabilitation facility (IRF) admission and services.
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) for the enrollee.

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 the services could be provided in another setting.

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 appears to be more stable and improving, but requires additional short-term acute care services which can be safely received at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. Transfer to a lower level of care may be considered when treatment has completed.

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) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and
panoramic x-ray (D0330).
You asked the Plan to pre-approve the comprehensive oral evaluation and panoramic x-ray. You say that you
do not understand why these services have been denied. The Plan denied your request. The Plan says these
services are not covered.
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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a
comprehensive oral evaluation (D0150) and panoramic x-ray (D0330).
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve SPECT imaging (78452).
You asked the Plan to pre-approve SPECT imaging. You say that you would like reconsideration because this service is medically necessary. The Plan denied your request. The Plan says that the member does not meet LCD criteria for coverage of the requested service.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 SPECT imaging. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found as the member is symptomatic with possible anginal type symptoms, is at intermediate risk for cardiovascular disease and cannot exercise adequately owing to her co-morbidities, she would meet the applicable CMS LCD 33560 criteria for Lexiscan SPECT nuclear cardiac stress testing. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SPECT imaging have been met. Therefore, we decided that the Plan has to pre-approve SPECT imaging (78452).
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.