Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for endovascular revascularization (open or percutaneous, transcatheter) procedures (37233) provided September 3, 2019.

You asked the Plan to pay for the endovascular revascularization. You say that enclosed is a corrected claim with the medical records to substantiate services provided. please process claim for payment. The Plan denied your request. The Plan says the records do not support the service billed.

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 37233 is open or percutaneous endovascular revascularization, of unilateral tibial/peroneal artery, for each additional vessel, with atherectomy, including angioplasty within the same vessel, when performed (listed separately in addition to code for primary procedure). 

We find that CPT code 37233 is not supported in the medical record. Specifically, CPT code 37233 was not documented in the narrative of the operative report. The operative report did not include documentation to meet the guidelines of an open or percutaneous endovascular revascularization, of unilateral tibial/peroneal artery, for each additional vessel, with atherectomy, including angioplasty within the same vessel, when performed (listed separately in addition to code for primary procedure). Based on this information, we decided that Medicare rules for coverage of the endovascular revascularization have not been met. Therefore, we decided that the Plan does not have to pay for endovascular revascularization (open or percutaneous, transcatheter) procedures (37233) provided September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on May 8, 2020 by an out of network (OON) provider.

You asked the Plan to pay for an office visit. You say that you had a referral for these services. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that the referring provider is out-of-network.

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 an office visit provided on May 8, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 11, 2020 by an out of network (OON) provider.

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 the services were 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 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 medical services provided on August 11, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the caries risk assessment (D0603) provided on
October 8, 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 caries risk assessment provided is not a
covered benefit under your dental policy.

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 caries risk assessment provided is
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
caries risk assessment (D0603) provided on October 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that without care, the enrollee will be unable to return to his current living situation safely. The Plan denied your request. The Plan says the enrollee does not require an intensive, complex, multidisciplinary approach to daily therapy.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 

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 physician reviewer found that the enrollee was admitted to the acute hospital for delirium, near syncope and third degree heart block. His medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing needs. The enrollee does not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. 

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says your medical needs are being met in the current acute setting.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that you were admitted to the current acute care hospital with acute encephalopathy related to suspected sepsis. You were treated with intubation, and later tracheostomy and PEG placement. Recent notes show that you are tolerating the trach collar during the day and are becoming more alert. You appear to be improving and only requires short term additional acute care services, which can be safely completed at the current facility. You do not require services at the LTACH that are not already being provided at the current facility. Therefore, this request for LTACH services is 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health visits (CPT Code(s): G0299 and G0152).

You asked the Plan to pre-approve the home health visits. You say that the services are necessary. The Plan denied your request. The Plan says the services are not 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 the home health visits. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve your condition, or to establish/perform a maintenance program to maintain your condition and/or prevent deterioration. The documentation does not reveal complex would care or other skilled nursing (SN) need. You have had extensive prior SN with education in disease management. The records do not show that skilled occupational therapy services are required to effectively provide treatment, care, and/or services in order to improve your level of function, or to establish/perform a maintenance program to maintain your level of function and/or prevent deterioration. Your needs do not require the skills of a professional therapist. As you do not require SN or skilled therapy services home health services are not reasonable and necessary to the treatment of your illness or injury by the skilled professional staff. 

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 home health visits have not been met. Therefore, we decided that the Plan does not have to pre-approve home health visits (CPT Code(s): G0299 and G0152).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical eye refraction provided on September 30, 2020.

You asked the Plan to pay for the medical eye refraction. You say that the eye refraction should be covered by
the Plan. The Plan denied your request. The Plan says eye refractions are only covered when billed by an innetwork
vision provider and billed as routine with a routine diagnosis. 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. We looked at the file and the
Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the medical eye
refraction have not been met. Review of the file show that you received the medical eye refraction on
September 30, 2020. The provider confirmed that the refraction was done for a medical diagnosis. Your 2020
EOC states that eye refractions are only covered when billed by an in-network vision provider and billed as
routine with a routine diagnosis. Your claim is billed with a medical diagnosis of primary open-angle
glaucoma, bilateral, mild stage (Diagnosis Code: H40.1131). Therefore, we decided that the Plan does not have
to pay for the medical eye refraction provided on September 30, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Albuterol inhaler.

You asked the Plan to pre-approve the Albuterol inhaler. You say that the drug in dispute is medically
necessary. The Plan denied your request. The Plan says the requested drug is intended for patient selfadministration.
The Plan says that the enrollee does not have Part D coverage under this contract.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve an Albuterol inhaler.

Benefits for the Albuterol inhaler may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit.

You asked the Plan to waive the copayment for the office visit. You say that you were in observation status for this date of service and should not have to pay. The Plan denied your request. The Plan says that medical records for this date of service indicate evaluation and management by a specialist.

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 $30 copayment for Physician/Practitioner services provided by a specialist. 

You have been asked to pay a $30 copayment for the office visit. The office visit falls within the Physician/Practitioner services 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 the office visit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on September 18, 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 had network providers available who could have provided 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 you by an out-of-network provider on September 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your
request. The Plan says there was no documentation of failure of four weeks of conservative treatment.

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 injection. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found there is no role for a series of three epidural steroid injections. Each injection should be evaluated for
degree and duration of effectiveness. Trials of various conservative therapy modalities are not clearly
documented. Therefore, at this point, the request is considered not medically reasonable or 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 the injection have not been met. Therefore, we decided that the Plan does not
have to pre-approve a lumbar epidural injection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral knee orthoses with suspension sleeves provided on September 24, 2020.

You asked the Plan to pay for the bilateral knee orthoses with suspension sleeves. You say that these services were medically necessary. The Plan denied your request. The Plan says Medicare criteria was not met.

The Plan follows Medicare rules. Medicare rules say that the ankle foot orthosis will not be covered unless knee instability has been documented by examination of the beneficiary and objective description of joint laxity. 

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 bilateral knee orthoses with suspension sleeves. Our reviewer says that the services were not medically reasonable and necessary. Our physician reviewer found there is insufficient documentation of an examination of the enrollee, and there is insufficient credible objective documentation of joint laxity. In addition, the item coded L2397 (sleeve) is not separately payable when the base item is not covered. 

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 bilateral knee orthoses with suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral knee orthoses with suspension sleeves provided on September 24, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not
require frequent rehab physician management, or an interdisciplinary approach to rehab care.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.

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 physician reviewer found
that you were admitted to the acute hospital for bilateral knee replacement. Your medical conditions are stable.
There are no medical needs requiring inpatient admission. There are no complex nursing needs. There is not a
reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation
therapy program provided in an IRF. While the medical record documents a need for physical and occupational
therapy, it does not document a need for an intensive rehabilitation program.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on July 10, 2020.

You asked the Plan to pay for the testing. You say that the services were necessary. The Plan denied your request. The Plan says this testing is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. The enrollee had cardiovascular risk assessment testing on July 10, 2020. The denial remains upheld as non-covered as Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for symptomatic enrollees with suspected or documented cardiovascular disease. Therefore, we decided that the Plan does not have to pay for cardiovascular risk assessment testing provided on July 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745) provided on May 9, 2020.

You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the documentation indicates that the item at issue is not necessary for the treatment of the enrollee's condition.

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 this item. Our reviewer says that the neuromuscular stimulator is not considered medically reasonable and necessary in this case. Our physician reviewer found that a physical examination of the ankles and feet would reasonably be required to adequately assess whether coverage criteria were met. The documentation does not support that the neuromuscular stimulator, electronic shock unit was medically reasonable and necessary in this case, as there is insufficient documentation of a credible physical examination of the ankles and feet. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this item have not been met. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electric shock unit (E0745) provided on May 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services rendered on June 25, 2020.

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 the services are not covered.

The Plan must follow Medicare rules. The rules say that RHCs and FQHCs may bill the Telehealth originating site facility fee on a RHC or FQHC claim under revenue code 0780 and HCPCS code Q3014. 

We looked at the file and Medicare rules. The file shows that the claim was billed with code G2025 with modifier 95. 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 telehealth services rendered on June 25, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve positron emission tomography (PET) scan services.

You asked the Plan to pre-approve the PET scan. You say that the member is enrolled in a clinical trial and the
requested PET scan is medically necessary. The Plan denied your request. The Plan says once a member signs
up for a Medicare approved clinical trial, Original Medicare is responsible for routine costs associated with
Medicare approved clinical trial services furnished to beneficiaries enrolled in managed care plans.

The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.

In this case, you asked the Plan to pre-approve the PET scan as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
positron emission tomography (PET) scan services.