Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation visit and injection of Fluid Flow.
You asked the Plan to pre-approve visit for Fluid Flow. You say that this service has been covered by Medicare in the past. The Plan denied your request. The Plan says this procedure is experimental/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 visit for Fluid Flow. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found high quality medical studies show that using specific amniotic membrane products may be useful for treating diabetic ulcers in some cases, for specific eye conditions, or for a disorder known as Stevens-Johnson syndrome. Using amniotic membrane for other conditions or using amniotic fluid products is considered unproven and investigational. 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 Fluid Flow have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation visit and injection of Fluid Flow.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 22, 2020.
You asked the Plan to reimburse you for the portable oxygen concentrator. You say that the Plan should reimburse you. Plan denied your request. The Plan says per Medicare guidelines payment is not made for purchases of oxygen and oxygen equipment.
The Plan must follow Medicare rules. Medicare rules say that only rented oxygen equipment is eligible for coverage. We looked at the file and Medicare rules. Purchased oxygen equipment is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to reimburse you for the portable oxygen concentrator purchased on June 22, 2020.
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 request is medically necessary. The Plan denied
your request. The Plan says rules for IRF care have not been met.
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 patient was admitted to an acute care hospital for left lower extremity vascular
bypass surgery. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary
care can be provided in a different level of care. There is not a reasonable expectation that this patient will be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on January 20, 2021.
You asked the Plan to pay for the eye exam. You say that the patient was in an assisted living facility at the time services were rendered and couldn't choose an in-network optometrist. You say that it is not possible to request authorization before services are rendered and the claim should be reprocessed for reimbursement. The Plan denied your request. The Plan says authorization wasn't obtained prior to the services being rendered.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the eye exam provided by an out-of-network provider on January 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services described by current procedural terminology (CPT) code S9342 provided from October 1, 2020 to October 31, 2020.

You asked the Plan to pay for CPT code S9342. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.

We looked at the file and Medicare rules. In this case, CPT code S9342 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services described by current procedural terminology (CPT) code S9342 provided from October 1, 2020 to October 31, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided January 21, 2021.

You asked the Plan to pay for the dental exam, bitewing x-rays and dental cleaning. You say that you would like the services covered. The Plan denied your request. The Plan says Medicare does not cover routine dental services and you do not have supplemental dental coverage under the Plan therefore, the services are not covered.

Medicare generally does not cover dental services. The Plan follows the same rule.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided January 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Tempus xO gene panel testing provided to the enrollee on December 16, 2019.

You asked the Plan to pay for the testing. You say that this is medically necessary. The Plan denied your request. The Plan says this panel is considered investigational, and not covered for personalized cancer care for any cancer type.

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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have malignant melanoma, which has recurred multiple times since it was initially diagnosed in 2005. While an office note indicates that genetic testing was to be performed, the note does not indicate how the testing would affect management of the enrollee. As such, the performed testing is not shown to have been medically necessary or reasonable. 

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for Tempus xO gene panel testing provided to the enrollee on December 16, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electroencephalogram described by current procedural terminology (CPT) code 95822 provided on August 24, 2020.
You asked the Plan to pay for CPT code 95822. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the electroencephalogram services were provided to the enrollee while the enrollee was inpatient. Therefore, we decided that the Plan does not have to pay for the electroencephalogram described by current procedural terminology (CPT) code 95822 provided on August 24, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment provided from October 1,
2020, to October 31, 2020.
You asked the Plan to pay for the durable medical equipment. You say that you would like the Plan to
reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as
billed.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.
Records show that the durable medical equipment was used in a SNF or hospital. Therefore, we decided that
the Plan does not have to pay for the durable medical equipment provided from October 1, 2020, to October 31,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on November 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the wound care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the wound care provided on November 13, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the Screening Pelvic Examinations (includes a clinical breast examination) described by current procedural terminology (CPT) code G0101 provided on December 29, 2020.
You asked the Plan to pay for CPT code G0101. 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 say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan denied payment for the Screening Pelvic Examinations (includes a clinical breast examination) described by current procedural terminology (CPT) code G0101 provided on December 29, 2020, stating that the enrollee had previously received this service on November 19, 2020 with another provider. However, the Plan has not provided any medical records to verify that this type of examination did take place or if the provider submitted an incorrect diagnosis code for the November 19, 2020 date of service. The Plan has also not provided any claims showing that CPT G0101 was previously paid. The Plan has not provided enough information to substantiate their reasoning for denial. Therefore, we decided that the Plan has to pay for the Screening Pelvic Examinations (includes a clinical breast examination) described by current procedural terminology (CPT) code G0101 provided on December 29, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that continued management can be provided in the acute care hospital until your course of care is complete.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The patient is currently undergoing treatment at an acute care hospital (ACH) for a urinary tract infection and sepsis. The enrollee is severely debilitated following a prior large stroke necessitating a tracheotomy, feeding tube and urinary catheter. Providers believe the enrollee is appropriate for Hospice, but the family is denying such care at this time. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213), a visual field examination (99213), and computerized ophthalmic diagnostic imaging (92133) provided on May 8, 2020.

You asked the Plan to pay for an office visit, a visual field examination, and computerized ophthalmic diagnostic imaging. You say that you thought the provider was in-network. The Plan denied your request. The Plan says The Plan says services are not covered when rendered by an out-of-network provider.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the provider is in-network.

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of an office visit, a visual field examination, and computerized ophthalmic diagnostic imaging have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. 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 an office visit (99213), a visual field examination (99213), and computerized ophthalmic diagnostic imaging (92133) provided on May 8, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve a SNF admission. You say that the enrollee needs SNF services. The Plan denied your request. The Plan says the enrollee can receive care needed in another setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 a SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found no required skilled nursing services are identified. The documentation does not support that it is medically reasonable and necessary to provide the therapy services on a daily basis on an inpatient basis in a skilled nursing facility. It is not medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a combination of these services) on a daily basis. This patient does not require the necessary services on 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 a SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the esophagogastroduodenoscopy (EGD) with anesthesia (43239, 00731).
You asked the Plan to pre-approve the diagnostic procedure. You say that your PCP has found that you have hemorrhoids and blood in your stool and sent a referral for you to see a specialist for endoscopy to check your small intestine. You are concerned that your health may be at risk The Plan denied your request. The Plan says the request for an esophagogastroduodenoscopy with upper bowel and monitored anesthesia does not meet medical necessity.
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 diagnostic procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the available record does not support that the enrollee meets the criteria for EGD. It can be argued that the enrollee's age places him at increased risk of sedation for which monitoring by anesthesia may be advantageous were the EGD to meet criteria. However, since enrollee does not meet EGD criteria, the issues are mute as to medical necessity and appropriateness of MAC for the EGD procedure under review. The question can be revisited once colonoscopy results as pending are posted. 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 diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the esophagogastroduodenoscopy (EGD) with anesthesia (43239, 00731).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and one power seating system motor (E2310).
You asked the Plan to pre-approve an electronic connection between wheelchair controller and one power seating system motor. You say that this request is medically necessary. The Plan denied your request. The Plan says the upgraded electronics are not medically necessary as there is no need to control the power option through the joystick.
The Plan follows Medicare rules. Medicare rules say that the electronic connection is subject to the coverage criteria listed 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 an electronic connection between wheelchair controller and one power seating system motor. Our reviewer says that the requested item is not medically necessary and reasonable. Our physician reviewer found that the documentation does not reveal that the patient requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The patient does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices), other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The patient's strength and functional ability indicates that the patient can control any power options through their own individual
switches. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an electronic connection between wheelchair controller and one power seating system motor have not been met. Therefore, we decided that the Plan does not have to pre-approve an electronic connection between wheelchair controller and one power seating system motor (E2310).