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

We decided that the Plan does not have to pre-approve a home ventilator.

You asked the Plan to pre-approve a home ventilator. You say that your provider feels this device is medically necessary. The Plan denied your request. The Plan says the requested item is not medically necessary.

The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 

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 home ventilator. Our reviewer says that the documentation does not support that the requested device is medically reasonable or necessary. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD), with a recent episode of hypercarbic respiratory failure. The patient may benefit from nocturnal bilevel positive airway pressure (BiPAP). But Medicare does not cover a home ventilator when used as BiPAP. There is no documented failure of BiPAP used in the home setting when medically stable. Therefore, you do not meet criteria for the requested device.

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 home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home ventilator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 12, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on May 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
You asked the Plan to pre-approve the dental services. You say that you need new dentures. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says that the frequency limit has been reached.
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 and partial dentures are listed as covered, the frequency limit has been reached. The record shows that the Plan paid for partial dentures that you received on February 9, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower denture (D5214).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for arthroscopic knee surgery coded as 29877 for the enrollee.
You asked the Plan to provide coverage for knee surgery for the enrollee. You say that this surgery is medically necessary. The Plan denied your request. The Plan says code 29877 cannot be separately requested as it is bundled with code 29880 which was approved.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, code 29877 was submitted in error due to its bundled relationship with code 29880 which was approved by the Plan. Therefore, we decided that the Plan does not have to provide coverage for arthroscopic knee surgery coded separately as 29877.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).

You asked the Plan to pre-approve dentures. You say that these dentures are necessary. The Plan denied your request. The Plan says you previously were provided with complete dentures on April 8, 2019. Dentures can only be covered once per jaw every five years. It has been less than five years since you previously received covered dentures, and therefore these services cannot be approved at this time.

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. The Plan can cover one complete denture per jaw every five plan years.

Though the Plan offers a dental benefit in excess of Medicare coverage, the dentures are requested in a frequency that is not covered under this benefit. Documentation shows that the Plan covered dentures for you less than five years ago. Therefore, we decided that the Plan does not have to pre-approve a complete upper denture (D5110) and complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for teeth # 23 and 25, and an implant supported removable lower denture (D6111).

You asked the Plan to pre-approve the dental services. You say that you have not been able to eat anything except for soup. You say that your denture broke 3 times. You also say that you need a new denture. The Plan denied your request. The Plan says custom fabricated abutment is not listed and therefore is not a covered service. The Plan says that implant supported removable lower denture is not listed as a covered service either.

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 custom fabricated abutments and implant supported denture are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) for teeth # 23 and 25, and an implant supported removable lower denture (D6111).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided April 19, 2021.
You asked the Plan to pay for foot orthotics. You say that you would like this claim reprocessed for medical
necessity. 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 pay for foot orthotics provided April 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the enrollee needs more medical attention in order to get the normal life back. The Plan denied your request. The Plan says that the enrollee's condition has improved and is no longer a threat to himself or others.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medically reasonable and necessary for the enrollee. It is not expected this enrollee would improve in a reasonable period of time as he was not showing any dangerousness to self or others, no auditory or visual hallucinations and no aggressive behaviors. This patient was compliant with treatment and having no side effects to the medication. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care as he does not have any suicidal or homicidal thoughts, auditory/visual hallucinations or aggressive behaviors. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for inpatient psychiatric hospital 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 inpatient psychiatric hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on April 18, 2021.

You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration because this testing is a medically necessary covered benefit. The Plan denied your request. The Plan says the provider did not bill any of the allowable diagnoses that will allow this service to process for 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.

We find that CPT code 0242U is not supported in the record. Specifically, per the LCA, Guardant360 testing is to be billed with CPT code 81479. This claim has not been submitted with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on April 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (G0279) provided on December 2, 2020.
You asked the Plan to pay for diagnostic digital breast tomosynthesis. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with a needed modifier.
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 1 indicates codes generally have both a professional and technical component. Modifiers 26 and TC can be used with these codes. We looked at the file and Medicare rules. The code at issue has a PC/TC indicator of 1, but was not billed with a modifier to indicate which component is being billed. Based on this information, we decided that Medicare
rules for coverage of diagnostic digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does not have to pay for diagnostic digital breast tomosynthesis (G0279) provided on December 2, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve one month rental of a vacuum assisted closure device with supplies, Negative pressure wound therapy electrical pump (E2402) negative pressure wound therapy dressings (A6550) and disposable canisters (A7000).
You asked the Plan to pre-approve wound therapy device and supplies. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the enrollee has exceeded 4 months of treatment of the recent wound. The pump was approved August 31, 2020.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. According to the records, the wound vac has been used for over nine months and the wound is deteriorating. The pump was initially approved in August of 2020. Based on this information, we decided that Medicare rules for coverage of wound therapy device and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve one month rental of a vacuum assisted closure device with supplies, Negative pressure wound therapy electrical pump (E2402) negative pressure wound therapy dressings (A6550) and disposable canisters (A7000).
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member's care needs can continue to be met in the skilled nursing facility setting.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for surgical repair of a hip fracture after a fall. The enrollee's 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services rendered on February 20, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99291 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of critical care services for 30-74 minutes spent on the enrollee. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services rendered on February 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve purewick external female urine collection device.

You asked the Plan to pre-approve purewick external female urine collection device. You say that you have
had urinary incontinence for the last 30 years. The Plan denied your request. The Plan says the requested item
is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that the purewick external urine collection device is only
covered for certain indications.

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 purewick external female urine
collection device. Our reviewer says that the documentation does not support that the requested items
medically reasonable or necessary. Our physician reviewer found you have unspecified nocturnal urinary
incontinence, retention and frequent urinary tract infections. You are not immobile. You do not have sacral
decubitus ulcer. You have venous stasis of the lower extremities. The documentation does not support that you
have a diagnosis/condition that meets criteria for the requested purewick external female urine collection
device. The records do not indicate the presence of decubitus ulcer, catheter acquired urinary tract infection or
completely confined to bed (immobility). Therefore, you do not meet criteria for the requested item.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of purewick external female urine collection device have not been met. Therefore,
we decided that the Plan does not have to pre-approve purewick external female urine collection device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from September 30, 2019, to October 3, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not supported.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. 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 the services provided from September 30, 2019, to October 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular screening testing provided on
February 11, 2021.
You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment tests/panels
for patients with suspected or documented cardiovascular disease.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover
this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary
cardiovascular screening testing provided on February 11, 2021.
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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services she needs in other settings.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for congestive heart failure, cirrhosis and kidney injury. The enrollee's 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 documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 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 for the enrollee.