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

We decided that the Plan does not have to pre-approvea Flexitouchpneumatic compression device (E0652) and sleeves (E0667).You asked the Plan to pre-approvea pneumatic compression device and sleeves. You say that these items are medically necessary for the enrollee.The Plan denied your request. The Plan saysthat the device is not covered for extremity swelling alone.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.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 has lymphedema extending onto the chest, trunk and/or abdomen.Therefore, we decided that the Plan does not have to pre-approvea Flexitouch pneumatic compression device (E0652) and sleeves (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on February 10, 2021.You asked thePlan to waive the copayment fora specialist visit. You say that this was a follow-up visit and you should not be responsible for the copayment.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 $45 copaymentfor specialist services. You had a specialist visit on February 10, 2021. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the allowed amount of $41.79, which is less than the $45 copayment. You have been asked to pay $41.79 for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveout-of-network chiropractic services.You asked the Plan to pre-approveout-of-network chiropractic services. You say that this provider is way closer than thein-network providers suggested.The Plan denied your request. The Plan says in-network providers are available.Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The Plan says that enrollees must use contract providers. The provider is a non-contract provider. We were able to confirm that the Plan has contract providers located within reasonable distance and travel time from your home who can provide out-of-network chiropractic services. Under Medicare rules, this means that contract providers are accessible to you.Therefore, we decided that the Plan does not have to pre-approveout-of-network chiropractic services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVertiflex surgery.You asked the Plan to pre-approveVertiflex surgery. You say that this service is medically necessary.The Plan denied your request. The Plan says this procedure is considered experimental and investigational.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 Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy of the device before coverage can be approved.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex surgery have not been met.Therefore, we decided that the Plan does not have to pre-approveVertiflex surgery
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean office visit for platelet-rich plasma (PRP) injection with ultrasound guidance.You asked the Plan to pre-approvevisit for PRP injection with guidance. You say that you tried a knee plasma injection and the treatment worked.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because studies have not proven that this treatmentis useful.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 visit for PRP injection with guidance. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found due to the lack of solid evidence for use of platelet-rich plasma (PRP) injections in patients with knee osteoarthritis it is not recommended. There is insufficient medical literature to establish the requested service as a standard of care and is still under clinical investigation.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of visit for PRP injection with guidance have not been met. Therefore, we decided that the Plan does not have to pre-approvean office visit for platelet-rich plasma (PRP) injection with ultrasound guidance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe power seat elevation feature (E2300).You asked the Plan to pre-approvethe power seat elevation feature. You say that this request is medically necessary.The Plan denied your request. The Plan says this benefitis not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. This item is statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the power seat elevation feature have not been met.Therefore, we decided that the Plan does not have to pre-approvethe power seat elevation feature (E2300).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to provide coverage for continued SNF services after May 13, 2021.
You asked the Plan to provide coverage for SNF care. You say that the enrollee suffers from dementia, which has been greatly exasperated by the infections and that the enrollee has been refusing medications and therapies at times because of her memory and once the infections are gone, she will return to her normal cooperative state. The Plan denied your request. The Plan says that skilled services are no longer medically necessary. The enrollee is now considered to be receiving custodial care.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a Notice of Medicare Non-Coverage (NOMNC) no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before May 13, 2021. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to provide coverage for continued SNF services after May 13, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora renal biopsy provided on March 15, 2021.You asked the Plan to waive the copayment fora renal biopsy. You say that the surgeon missed the spot the first time and it had to be redone and you feel that you should not owe the second copayment.The Plandenied 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 $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities.The record shows that you received a renal biopsy at an outpatient hospital facility on March 15, 2021. Therefore, you are responsible to pay the $400 copayment.  You have been asked to pay a $400 copayment for a renal biopsy. A renal biopsy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 fora renal biopsy provided on March 15, 2021.We note your complaint that the surgeon missed the spot during the initial biopsy. Your complaint is a grievance that mustbe 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 forwound care provided on March 12, 2021, by an OON provider.You askedthe Plan to pay forwound care. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says the member's facility failed to obtain prior authorization. The Plan says that the member's primary care physician did not refer these services.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 carefrom 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 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 forwound care provided on March 12, 2021, by an OONprovider.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay forthe computed tomography (CT) scan represented by code 70450-26-59-X5 provided on January 31, 2021.You asked the Plan to pay forcode 70450-26-59-X5. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services are not covered.The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service.  The medical records provided show that the service billed with the-59 modifier is a distinct procedural service. Specifically, the medical records show code 70450 represents a different session or patient encounter. Based on this information, we decided that Medicare rules for coverage of services billed with a -59 modifier have been met.Therefore, we decided that the Plan has to pay forthe computed tomography (CT) scan represented by code 70450-26-59-X5 provided on January 31, 2021.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the duplex scan of extracranial arteries, complete bilateral study (93880) provided January 27, 2021.

You asked the Plan to pay for the duplex scan. You say that you would like to see the member responsibility removed as you were not advised that authorization was required and denied prior to having the duplex scan The Plan denied your request. The Plan says the records do not support that the requested service is 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 pay for the duplex scan. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there was no specific clinical rationale for the requested carotid studies. There was no documentation of any abnormal carotid upstroke, bruit or TIA symptoms. The review has determined that the medical records provided did not meet the requirements listed in the LCD for Medicare coverage.

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 duplex scan have not been met. Therefore, we decided that the Plan does not have to pay for the duplex scan of extracranial arteries, complete bilateral study (93880) provided January 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea cervical epidural steroid injection (ESI).You asked the Plan to pre-approvethese services. You say that you disagree with the denial.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 received an interlaminar cervical epidural steroid injection on April 6, 2021 and had two weeks of 20 percent pain relief with functional improvement. She did not have documented pain relief for at least three months' duration. The requested repeat cervical ESI is not the standard of care and is not reasonable or medically necessary 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 ofthese services have not been met.Therefore, we decided that the Plan does not have to pre-approvea cervical epidural steroid injection (ESI)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintermittent limb compression device.You asked the Plan to pre-approveintermittent limb compression device. You say that the records provided support the medical necessity of the item in dispute.The Plan denied your request. The Plan says the records do not show that the enrollee meets the criteria for coverage.The Plan follows Medicare rules. The rules state that Medicare covers pneumatic devices when medically necessary for the treatment of lymphedema and/ or for the treatment of chronic venous insufficiency with venous stasis ulcers.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 intermittent limb compression device. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the documentation does not support the medical necessity of the device in question.  The medical records provided do not demonstrate lower extremity edema or an assessment and plan that includes a recommendation for the use of a pneumatic compression device.  Records from two different providers are included, neither of which suggest significant edema, lymphedema, or need for such a device.  One of the providers specifically documents that there is noedema.  Both providers documented palpable extremity pulses.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of intermittent limb compression device have not been met.Therefore, we decided that the Plan does not have to pre-approveintermittent limb compression device.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Dexcom G6 CGM.You asked the Plan to pre-approvethe Dexcom G6 CGM. You say that you would like reconsideration because the preferred sensor will not meet the member's needs.The Plan denied your request. The Plan says the member has not had a trial of the preferred product.The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Dexcom G6 CGM have not been met. Specifically, the documentation submitted does not include any clinical information to determine if Medicare coverage criteria have been met. There is no evidence that the member has tried the Plan's preferred brand or that the Plan's preferred brand would be contraindicated for the member.Therefore, we decided that the Plan does not have to pre-approvethe Dexcom G6 CGM.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay forthe colonoscopy, flexible, with biopsy, single or multiple (45385) provided on October 15, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe diagnostic procedure. You say that due to a provider ID issue with the Plan, you are receiving some invalid prior authorization denials. Please review and reprocess your claim.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered. Medicare rules say that planscan 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 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 forthe colonoscopy, flexible, with biopsy, single or multiple (45385) provided on October 15, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99232) provided January 11, 2021.You asked the Plan to pay forthe hospital care. You say that the services were medically necessary.The Plan denied your request. The Plan says the billed service is not payable.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 code 99232 is not supported in the medical record. Specifically, Subsequent Hospital Care codes are "per diem" services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. The record shows a claim was already paid for an evaluation and management service on the same date of service for the same physician group. Based on this information, we decided that Medicare rules for coverage of the hospital care have not been met.Therefore, we decided that the Plan does not have to pay forhospital care (99232) provided January 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot inserts (L3001, L3020) and heel stabilizers (L3170).
You asked the Plan to pre-approve foot inserts and heel stabilizers. You say that the Plan's listed pretext for denial is very unreasonable. 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 inserts (L3001, L3020) and heel stabilizers (L3170).