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

 
We decided that the Plan does not have to pay for the pneumatic compression device, high pressure, rapid 
inflation/deflation cycle, for arterial insufficiency (E0675) segmental gradient pressure pneumatic appliance 
(E0673) provided March 6, 2020. 
 
You asked the Plan to pay for the pneumatic compression device and appliance. You say that please see 
attached for more information on the product provided for this enrollee during her surgery. The physician 
ordered the DME item used to prevent deep vein thrombosis or blood clots as well as pulmonary embolism. 
The Plan denied your request. The Plan says this item is not covered. Payment for this service would have been 
included in the facility DRG or PPS payment. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. The facility or hospital must furnish all necessary 
covered services to the beneficiary either directly or under arrangements made with outside providers. The 
enrollee used the equipment in the facility during and/or after surgery. All equipment used within the hospital 
or ambulatory surgical center is the financial responsibility of the facility. Payment for this service is the 
responsibility of the facility or hospital that provided the surgery. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial 
insufficiency (E0675) segmental gradient pressure pneumatic appliance (E0673) provided March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe durable medical equipment (DME) you received on January 3, 2020.You asked the Plan to pay forthe DME. The Plan denied your request. The Plan says the service was billed with the incorrect place of service.The Plan must follow Medicare rules. Medicare rules say that the place of service indicates the place in which the item is being used. We looked at the file and Medicare rules.The non-contract provider billed the DME item with an "office visit" place of service (POS code 11). The item must be billed with the place of service in which the item will be used. The physician's office is not where the DME will be used.Based on this information, we decided that Medicare rules for coverage of the DME have not been met.Therefore, we decided that the Plan does not have to pay forthe durable medical equipment (DME) you received on January 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 5 home health skilled nursing visits (G0299). 
 
You asked the Plan to pre-approve 5 home health skilled nursing visits. You say that the 5 requested home 
health skilled nursing visits are medically necessary. The Plan denied your request. The Plan says the 5 
requested home health skilled nursing visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 5 home health skilled nursing visits. 
Our reviewer says that the 5 requested home health skilled nursing visits are not medically necessary. Our 
physician reviewer found the documentation doesn't support that the member requires skilled nursing services 
or skilled rehab services to provide treatment that is medically necessary. The member does not require skilled 
nursing or rehab services to effectively provide treatment, care, and/or services in order to improve the 
member's condition, perform a maintenance program to maintain the enrollee's condition and/or prevent 
deterioration.  There is no documentation to support that she requires skilled nursing visits.  Furthermore, it is 
not clear that she is homebound given that she is independent with ambulation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 5 home health skilled nursing visits have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 5 home health skilled nursing visits (G0299).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health aide services. 
 
You asked the Plan to pre-approve aide services. The Plan denied your request. The Plan says the enrollee has 
no new or acute diagnosis. Her conditions are chronic in nature. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
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 aide services. Our physician reviewer 
found that the documentation does not support that the enrollee requires skilled nursing or rehab services to 
effectively provide treatment, care, or services in order to improve her condition. She does not require skilled 
services to maintain her condition or prevent deterioration. The enrollee has a willing caregiver to assist with 
activities of daily living. Home health aides cannot be approved if there is not a skilled need. Therefore, the 
requested services are not medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of aide services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health aide services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MyoPro myoelectric orthosis for the enrollee. 
 
You asked the Plan to pre-approve the orthosis. You say that this is medically necessary. The Plan denied your 
request. The Plan says the peer reviewed medical literature considers the MyoPro myoelectric orthosis 
experimental and investigational for this enrollee's clinical scenario. 
 
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 orthosis. Our reviewer says that the 
requested orthosis is not considered medically reasonable and necessary in this case. Our physician reviewer 
found at this time the requested robotic orthosis is not proven to be more beneficial for treatment of the 
enrollee's medical condition/function of hemiparesis after stroke than any available standard therapy. The 
requested device is not reasonable and necessary for the diagnosis or treatment of an illness or injury or to 
improve the functioning of a malformed body member. 
 
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 orthosis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the MyoPro myoelectric orthosis for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested 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 admission to a LTACH is not medically necessary. Our physician reviewer found there is no documentation provided requiring admission to a LTACH.At the time of the request, the member's status is critical and unstable. The member is receiving medically necessary acute and/or critical care. The enrollee still requires acute hospital level of care and is receiving appropriate are at the present acute care facility. 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.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran inpatient hospital stay provided by a participating provider on May 7, 2020 to May 14, 2020.You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you do not feel like you received enough care to warrant this copayment. The Plan denied your request. The Plan says the correct copayment has been applied to the services that were provided.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 inpatient hospital care. You have been asked to pay a $250 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital care 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 an inpatient hospital stay provided by a participating provider on May 7, 2020 to May 14, 2020. We note your complaint about not feeling like you received care. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered on December 31, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 88342 and 88188. Code 88342 is a column II code with a modifier indicator of 1 when billed with column I code 88188. Code 99283 was not billed with an appropriate modifier to allow for separate payment. 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 88341 is immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody stain procedure (List separately in addition to code for primary procedure),We find that CPT code 88341 is not supported in the medical record. Specifically, this is an add-on code that was not billed with a required primary procedure code. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered on December 31, 2019
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve cardiac computed tomography (CT) with calcium 
scoring (75571). 
 
You asked the Plan to pre-approve the CT scan with calcium scoring. You say that this test is medically 
necessary. The Plan denied your request. The Plan says you have no symptoms of cardiac disease, and 
therefore this test is 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 CT scan with calcium scoring. Our 
reviewer says that the requested cardiac imaging is not medically necessary. Our physician reviewer found 
based on the records the enrollee has increased coronary risk but no evidence of coronary disease. In this 
circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are 
periodically updated by expert committees and are endorsed by several national organizations. These 
guidelines currently do not recommend routine performance of specialized tests in the context of assessing 
coronary risk, including coronary CT scanning and calcium scoring. 
 
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 CT scan with calcium scoring have not been met. Therefore, we decided 
that the Plan does not have to pre-approve cardiac computed tomography (CT) with calcium scoring (75571).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (81490) rendered by the out of 
network (OON) provider on February 3, 2020. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network 
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 provider in this case is not a network provider with the Plan. The Plan has network providers available 
who can provide the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found 
no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not 
have to pay for the laboratory service (81490) rendered by the out of network (OON) provider on February 3, 
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-
network provider on July 6, 2020. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at 
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that 
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider 
on July 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs HF System. 
 
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has NYSHA Class III 
congestive heart failure with preserved left ventricular ejection fraction (LVEF 65%) requiring hospitalization. 
In this circumstance, therapy change based on data obtained from a CardioMEMs device has been 
demonstrated in only one trial to help reduce hospital readmission compared to standard medical therapy. The 
efficacy of CardioMEMs is uncertain due to leading authorities and not recommended in current guidelines for 
the treatment of heart failure. The services are considered experimental/investigational in nature and not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. 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 CardioMEMs HF System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves, and neuromuscular 
stimulator provided on March 20, 2020. 
 
You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397), and neuromuscular 
stimulator (E0745). You say that the orthoses and stimulator were medically necessary. The Plan denied your 
request. The Plan says the orthoses and stimulator are not supported in the medical records received. 
 
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 knee orthoses (L1851) and suspension 
sleeves (L2397), and neuromuscular stimulator (E0745). Our reviewer says that the orthoses and stimulator are 
not medically necessary. Our physician reviewer found the enrollee's chief complaint was knee pain. The 
documentation in the case file does not support that the requested knee orthoses with sleeves were medically 
reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the 
LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's 
knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) 
is not separately payable when the base item is not covered. 
 
The documentation does not support that the NCD coverage criteria for a neuromuscular electrical stimulation 
device, as established by NCD 160.12, have been met 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 the knee orthoses (L1851) and suspension sleeves (L2397), and Neuromuscular 
stimulator (E0745) have not been met. Therefore, we decided that the Plan does not have to pay for the knee 
orthoses and suspension sleeves, and neuromuscular stimulator provided on March 20, 2020.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve affirming surgery. 
 
You asked the Plan to pre-approve mastectomy with reconstruction. You say that this is the next appropriate 
step to make significant progress in further treatment. The Plan denied your request. The Plan says that bilateral 
mastectomy and reconstruction criteria is not met. 
 
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 mastectomy with nipple reconstruction. 
Our reviewer says that the requested services are considered medically reasonable and necessary in this case. 
Our physician reviewer found The Plastic Surgery History and Physical  documents that 
the enrollee has undergone appropriate counseling and preparation and meets WPATH guideline for the 
requested surgery. The enrollee has been under care and it has been determined that the enrollee is quite stable 
and is emotionally healthy to undergo the surgery. Coverage determinations for transgender surgery are 
determined on a case-by-case basis with particular consideration of the World Professional Association for 
Transgender Health (WPATH) Standards of Care as interpreted through the various Medicare statutes, rules, 
regulations, and Manual instructions. It has been determined that any coexisting psychological, medical, or 
social problems that could interfere with treatment have been addressed, and the enrollee is sufficiently stable 
to proceed with the requested surgery. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of mastectomy with nipple reconstruction. have been met. Therefore, we decided 
that the Plan has to pre-approve affirming surgery.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on 
May 7, 2020. 
 
You asked the Plan to pay for genetic testing. You say that the enrollee's treating physician ordered this testing 
to determine if there was a more effective therapy for the enrollee's condition. The Plan denied your request. 
The Plan says the denial of payment for this testing is correct, because this testing was not billed with the 
appropriate coding. 
 
The Plan must follow Medicare rules. Medicare rules say that CGP testing must be billed with CPT code 81479 
for date of service May 7, 2020.  
 
We looked at the file and Medicare rules. This testing was not billed with the appropriate coding. Based on this 
information, we decided that Medicare rules for coverage of genetic testing have not been met. Therefore, we 
decided that the Plan does not have to pay for comprehensive genomic profile (CGP) testing provided on May 
7, 2020.